{"id":91,"date":"2021-03-04T17:04:28","date_gmt":"2021-03-04T17:04:28","guid":{"rendered":"https:\/\/www.bikhamhealthcare.com\/provider-resources\/?p=91"},"modified":"2026-02-03T20:32:25","modified_gmt":"2026-02-03T20:32:25","slug":"how-to-get-paid-more-for-your-medical-procedures-negotiate-for-higher-payer-reimbursement-rates-for-your-practice","status":"publish","type":"post","link":"https:\/\/www.bikhamhealthcare.com\/provider-resources\/how-to-get-paid-more-for-your-medical-procedures-negotiate-for-higher-payer-reimbursement-rates-for-your-practice\/","title":{"rendered":"How to Get Paid More for Your Medical Procedures: Negotiate for Higher Payer Reimbursement Rates for Your Practice"},"content":{"rendered":"\n

It\u2019s a new year and that means that it may be time for your practice\u2019s annual checkup. Checkup? We\u2019re talking revenue here – specifically, gaining more revenue by negotiating with your payers for higher reimbursements.<\/p>\n\n\n\n

\u201c\u2026 Negotiating with payers for fairer payments is not impossible,\u201d writes Dr. Gregory J. Mertz, MBA, FACMPE, in this article<\/a> from the American Association of Family Practitioners Foundation (AAFP). \u2018\u2019With the right data and a reasonable approach, you may be able to overcome some inequities in existing fee schedules.\u201d<\/p>\n\n\n\n

Why You Should Negotiate for Higher Reimbursement Rates for Medical Services<\/strong><\/h2>\n\n\n\n

Pre COVID-19, it\u2019s no secret that healthcare costs keep rising. Then, in 2020, the Medical Group Management Association reported that 97% of PCP and specialty practices suffered a financial impact related to the COVID pandemic, and, nationwide, we saw a 55% drop in physician practice revenues<\/a>. <\/p>\n\n\n\n

Whether or not your practice has been impacted, more equitable reimbursement rates can stabilize your financial future so you can continue to provide excellent patient care.    <\/p>\n\n\n\n

The Best Time to Negotiate for Higher Payer Reimbursement Rates<\/strong><\/h3>\n\n\n\n

As we know, annual checkups are all about being proactive, not reactive. Ditto for scrutinizing your payer contracts and overall revenue cycle. Ideally, your practice should conduct an annual review of all your health plan contracts – including each contract\u2019s addendums or clauses. Also, there are three changes that should send you to that filing cabinet:<\/p>\n\n\n\n

(1)<\/strong> changes or updates to CPT codes<\/a>.<\/p>\n\n\n\n

(2)<\/strong> A recent (2020) shift in your service line(s) and related patient cohorts.<\/p>\n\n\n\n

(3)<\/strong> You suspect or know that some contracts have outdated codes that are no longer accepted.<\/p>\n\n\n\n

Who Can Help You in the Payer Negotiation Process<\/strong><\/h2>\n\n\n\n

In a recent article<\/a> in \u201cBehavioral Health Executive,\u201d San Francisco-based Attorney Nathaniel Winer stresses the importance of supporting your payer-provider contract negotiations with strong health-outcomes data and metrics.<\/p>\n\n\n\n

\u201cThe payer\u2019s language now is data,\u201d says Winer. \u201cShow us what your data is for outcomes, how you can improve the cost curve and provide better care.\u201d <\/p>\n\n\n\n

In other words, you won\u2019t get higher rates just because you ask. Instead, before you contact your payers, assemble a strong, data-supported business case that demonstrates your practice\u2019s positioning and value within the payer\u2019s network.  In turn, building your case will require working with your practice\u2019s internal and external stakeholders.   <\/p>\n\n\n\n

Internal stakeholders: <\/strong>  Every health system is different, but typical inter-departmental or practice allies will be your EMS and billing professionals, office and practice managers and those clinical managers who oversee under-performing service lines.  Educate yourself about the fee negotiation process<\/a>, and, if you lack the in-house resources to gather the needed data, enlist some Revenue Cycle Management (RCM) expertise<\/a>.    <\/p>\n\n\n\n

External stakeholders:  <\/strong>Typically, your first approach to your target health plans will be to the plan\u2019s provider relationship representative who, in turn, may engage the contracting manager. Requesting higher rates for an a-typical or lesser-known medical service? The health insurance\u2019s medical director may support your case, but will not engage in the actual provider-payer negotiations.<\/p>\n\n\n\n

Pick Your Battles:  What to Include in Your Rate Negotiations Business Case<\/strong><\/h3>\n\n\n\n

Even with a strong business case, don\u2019t expect a unilateral or across-the-board rate increase. Instead, research and list the most frequently billed CPT codes, or those services that provide demonstrable value or health-spend savings within the provider network. For example, do you provide best-practice chronic-disease management? Has your patient care decreased high-cost inpatient or ED visits? Also, as many commercial payers\u2019 base their rates on a percentage of Medicare\u2019s fixed fee schedules, know the Medicare rates. You can find Medicare\u2019s current rates for your geographic area through the \u201cMedicare Physician Fee Schedule Look-Up<\/a>\u201d tool.  Base your cost calculations on the payer\u2019s \u201callowed\u201d not actual \u201cpaid\u201d amount, and consider including ancillary – including laboratory – charges.<\/p>\n\n\n\n

Next, shortlist your target health plans. This list may include the lowest-rate payers and\/or the plans that correspond with your practice\u2019s high-use or high-value services. Finally, present your practice\u2019s patient data in a clear, easy-to-understand format (spreadsheets and\/or graphics) and get ready to negotiate with your payers for mutual success.  <\/p>\n\n\n\n

At first glance, asking your payers to pay more for selected medical services may seem like the proverbial David and Goliath setup.  However, with the right approach and with a clear, data-supported business case, you may be able to safeguard or advance your practice\u2019s 2021 revenues and financial health.<\/p>\n","protected":false},"excerpt":{"rendered":"

It\u2019s a new year and that means that it may be time for your practice\u2019s annual checkup…<\/p>\n","protected":false},"author":1,"featured_media":2380,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[16],"tags":[],"class_list":["post-91","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medical-billing"],"yoast_head":"\nHow to Get Paid More for Your Medical Procedures: Negotiate for Higher Payer Reimbursement Rates for Your Practice - Bikhamhealthcare :: Provider Resources<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.bikhamhealthcare.com\/provider-resources\/how-to-get-paid-more-for-your-medical-procedures-negotiate-for-higher-payer-reimbursement-rates-for-your-practice\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" 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