A payer contract sets reimbursement, timely filing limits, appeal rights, termination terms and the products you participate in. Most practices sign whatever arrives because the credentialing wait was long and they want to start billing. Rates below Medicare, unilateral amendment clauses and 90-day filing limits get locked in without anyone reading them.
ClainetRCM reviews the agreement clause by clause, models the fee schedule against your actual code mix, and tells you what it is worth. Where the practice has leverage, through volume, geography or a service the payer needs, we negotiate. Where it does not, we tell you that too.
Where this usually goes wrong
What ClainetRCM handles
One coordinator owns the file from intake to effective date, so you always know who to call and what is outstanding.
- Line-by-line contract review with a plain-language summary of key terms
- Fee schedule modeling against your top 25 CPT codes and Medicare rates
- Product participation review so you know exactly which plans you are joining
- Negotiation of rates and terms where volume, specialty or geography support it
- Executed contract and fee schedule loaded into the practice management system
- Annual contract inventory with renewal dates and renegotiation opportunities
Contract terms that deserve attention
| Reimbursement | Basis of the fee schedule, the year of Medicare it references, and whether it updates. |
|---|---|
| Products | Commercial, exchange, Medicare Advantage, Medicaid managed care, narrow networks. |
| Timely filing and appeals | Days to file a claim and to appeal a denial. Some contracts allow as few as 90 days. |
| Amendments | Whether the payer can change rates or terms unilaterally with notice. |
| Termination | Notice period, without-cause termination rights, and continuity of care obligations. |
| Credentialing standards | Re-credentialing cycle and requirements. See re-credentialing. |
We review contracts for every payer we credential with, including Medicare Advantage plans whose rates are often stated as a percentage of Medicare.
How the work runs
The sequence is the same for every payer and provider type; what changes is which documents and portals each step touches.
- Intake and gap review
Licenses, DEA, board certificates, malpractice, work history and NPI details are collected and compared against what each target payer asks for.
- Profile setup
CAQH ProView, PECOS and payer portals are created or cleaned up, attested and linked to the correct Tax ID and locations.
- Application submission
Every enrollment is filed in dependency order, with a tracking record for each payer, date and reference number.
- Follow-up on a fixed cadence
Payers are contacted on a schedule. Requests for more information are answered the same business day.
- Approval, contract and handoff
Effective dates, provider IDs and fee schedules are logged and loaded into your billing system.
Frequently asked questions
Can a small practice negotiate payer rates?
Sometimes. Leverage comes from being the only provider of a specialty in an area, serving a large employer's workforce, or having volume the payer needs. We assess leverage honestly before spending time on a negotiation.
How do I know if my rates are below market?
Compare each contract's payment for your top codes to the Medicare fee schedule and to your other commercial contracts. We build that comparison in the initial review and repeat it annually.
What if I already signed a bad contract?
Most contracts allow termination or renegotiation with notice, often 90 to 180 days. We identify the renegotiation window and prepare the request with supporting data.
Is contracting included in credentialing?
Contract review and loading are included with every credentialing engagement. Active negotiation is scoped separately based on the number of payers and the leverage available. See credentialing cost.
Read next
Or return to the provider credentialing overview.