Reimbursement terms, filing windows, appeal rights and termination provisions live in a contract most practices signed years ago and have never compared against actual payments. Everything you argue with a payer about is decided by a document nobody has read.
Somewhere in your office is a contract with each payer you bill. It sets your rates, your filing deadlines, your appeal rights, and what happens when either side wants out. Most practices signed it once and have not looked since.
What is actually in it
- The fee schedule, or the basis for one — frequently a percentage of a published rate, which moves when that rate does.
- Timely filing, which is contractual and varies widely. Yours may be shorter than you assume.
- Appeal rights and deadlines, including how many levels you get and in what form.
- Recoupment terms — how far back they may look and how much notice they owe you.
- Escalation and termination, including notice periods and whether rates renew automatically.
Why not reading it costs money
You cannot detect an underpayment without knowing the contracted rate. Practices routinely accept payments below contract for years, because a paid claim looks identical to a correctly paid claim in every report.
You also cannot argue a filing denial without knowing your actual window, and "we thought it was ninety days" is not a position.
The hour that pays for itself
Pull your three largest payers by revenue. Find the fee schedule basis, the filing window, and the appeal deadline for each. Write those nine facts on one page.
Then take twenty recent remittances and compare the allowed amounts against what the contract says. If they match, you have confirmed something worth knowing. If they do not, you have found a recurring leak that no report was going to surface on its own.
Extract the operational terms onto one page
Filing window, appeal levels and deadlines, authorization obligations, and the fee schedule reference. Staff will never read a forty-page agreement and do not need to — they need those four things per payer, where they work.
That page is also what turns a vague sense that a payer is behaving badly into a specific breach you can raise.
Diary the renewal, not the expiry
Many contracts renew automatically unless notice is given within a defined window before the anniversary. Missing that window commits you for another term at the current rates.
Set the reminder for the notice deadline rather than the renewal date, because by the renewal date the decision has been made for you.
Check rates after every change
Renegotiated rates that were never loaded — by the payer, or in your own system — pay silently at the old amount. Verify against remittances in the first month after any change takes effect.
Common questions
- What should I look for in a payer contract?
- The fee schedule and how it updates, timely filing and appeal windows, prior authorization obligations, termination notice, and whether rates renew automatically.
- How often should payer contracts be reviewed?
- Annually at minimum, and always before a renewal date. Many contracts renew automatically unless notice is given within a window.
- Can I negotiate a payer contract as a small practice?
- Sometimes, particularly on specific codes where you have volume or where you are the only local provider. General rate negotiation is harder than targeted requests.
- How do I know if a payer is paying the contracted rate?
- Compare remittances against the fee schedule for your highest-volume codes. Underpayments look identical to correct payments in every standard report.
- Where do filing and appeal deadlines come from?
- The contract, and they frequently differ from what staff assume. Extracting them into a reference sheet is the highest-value hour in a contract review.
Denials Piling Up?
We handle the revenue cycle end to end — coding by certified coders, claim submission, denial management and appeals, and A/R follow-up, with six reported numbers every month.