Payer Contract Negotiation Checklist (Download)

1. Reimbursement Rate Review

1. Confirm current reimbursement rates for your top 20 billed CPT codes by volume
2. Compare proposed rates against Medicare fee schedule as a baseline benchmark
3. Check for carve-outs or exceptions on high-volume or high-cost codes
4. Confirm whether rates are a flat fee, percentage of billed charges, or percentage of Medicare
5. Verify the rate effective date and whether it applies retroactively or prospectively

Medwave’s approach: Our payer contracting team benchmarks proposed rates against both Medicare and a proprietary comparison across our own book of the 15,000+ providers (we’ve worked with) before any client signs.

2. Payment Terms Review

1. Confirm timely filing limits for initial claims
2. Confirm timely filing limits for corrected claims and appeals
3. Check prompt payment / interest penalty provisions for late payer payment
4. Review claims processing timelines and whether they’re enforceable
5. Confirm electronic payment (ERA/EFT) is supported and required

3. Contract Risk Review

1. Identify auto-renewal clauses and required notice periods to opt out
2. Check for unilateral rate change provisions (can the payer change rates without your agreement?)
3. Review termination clauses, including termination without cause
4. Check for most-favored-nation clauses that could limit future negotiations with other payers
5. Review any value-based care or risk-sharing provisions and how they’re measured

4. Protective Language Checklist

1. Confirm the contract explicitly lists which services and codes are covered
2. Confirm language addressing new or unlisted CPT codes added after signing
3. Confirm language protecting against post-authorization claim denials
4. Confirm dispute resolution and appeals process is clearly defined

Medwave’s approach: We flag three specific protective phrases in every contract review, see our full breakdown in Payer Contract Negotiation: 3 Protective Phrases Every Healthcare Provider Needs.

5. Administrative Burden Review

1. Review prior authorization requirements by service category
2. Review documentation requirements for claims submission
3. Confirm credentialing and recredentialing timelines tied to the contract
4. Review any reporting requirements tied to value-based arrangements

6. Renewal and Renegotiation Triggers

1. Set a calendar reminder at least 90 days before any auto-renewal or opt-out deadline
2. Flag contracts with reimbursement rates unreviewed in more than 2 years
3. Flag contracts where denial rates have risen since signing
4. Flag contracts predating major changes to your service mix or patient volume