Payer contract review checklist for medical practices

Agreement and participation scope

Locate the executed contract and every later amendment. Note the contracting entity, payer products and networks covered. Do not assume that a single payer-brand name means the same agreement applies to every plan.

• Effective date, term, automatic renewal and notice deadline.
• Required notice method and current contract contact.
• Provider roster and participation obligations.
• All-products provisions and the process for adding networks or plans.
• Termination and amendment provisions for qualified legal review.

Fee schedule and incorporated policies

Find the actual rate exhibit and any later revisions. If the contract refers to another document or payer policy, identify the version in use. A percentage of Medicare is incomplete without the applicable year and payment basis.

• Fixed dollar rates or percentage-based formula.
• Medicare base year, locality and facility/non-facility basis where applicable.
• Highest-volume CPT/HCPCS codes, units and relevant modifiers.
• Bundling, multiple-procedure and lesser-of payment rules.
• How and when rate or policy changes take effect.

Payment evidence and practice priorities

Prepare summaries by payer, product and code rather than patient-level records. Use permitted, deidentified information to distinguish contractual rates from allowed amounts and collected cash.

• Approximate annual commercial billing and code-level units.
• Current contracted and observed allowed amounts for the same services.
• Recurring denials, adjustments or implementation discrepancies.
• Which payer relationships matter most to the practice.
• The question to resolve: low rates, unclear terms, payment errors or renewal timing.

Questions to ask about reimbursement clauses

These questions flag issues for review; they are not legal conclusions about an individual agreement. Contract language and applicable law matter. The AMA’s contracting checklist is a useful additional starting point.

• Can the payer amend rates or incorporated policies, and what notice or objection process applies?
• Does accepting one product require participation in others?
• Can a network lease or extend access to the contracted rate?
• Do timely-filing and appeal deadlines leave enough time for your workflow?
• Does a lesser-of provision limit payment when billed charges are below the schedule?
• Does a stated increase also change the schedule year, scope or payment rules?

What to send for an initial conversation

Your specialty, location, main commercial payers and the concerns you want reviewed are enough to request a first discussion. Missing documents can be identified during that conversation. Do not paste contracts, patient details or claim-level records into a public contact form.

NPAG’s initial strategy call is 30 minutes. A paid analysis is a separate engagement; review its scope and fees before deciding. Gathering documents or identifying an old commercial contract does not commit you to a service or guarantee higher reimbursement.