The first step to assessing your payor contracts is to obtain a copy of the signed and executed contract from each contracted payor. If you do not have a copy on file, you can request a copy from the payor.
You should have physical copies of all executed payor agreements in a secure location. These documents are important for understanding obligations that both you and the payor have agreed to and provide the basis for resolving disputes. They also establish the basis for future changes to agreements.
Unless your contracts are very recently executed, chances are that the payor has made additions or modifications to the contract that you originally signed. Ask the payor which sections of the contract have been modified over time and request copies of each letter notifying you of each modification, including the date that the modification was effective. If possible, request a copy of your original contract with new language underlined and red-lined of deleted language. If a payor is non-responsive to your requests for a copy of your contract, follow-up with a demand letter (see Attachment A-1 for a sample letter).
You should demand the fee schedule from all payors for each and every service to be provided pursuant to the contract. Fee schedules are an integral part of your contract with the payor and it is imperative that you review and approve the fee schedule before signing any contract. You must know what you will be paid in order to decide if the contract makes good business sense.
Failure to review the fee schedule in detail may result in you getting stuck in a money-losing relationship.
It may be helpful for the practice to identify its top CPT codes (based on utilization in general, or for the specific services you are selling to this payor) and fax or email this list of codes to the payor with the request that they provide you with the corresponding fees. In addition to the fee schedule, it is important to have access to the payor’s provider manual, medical policies and payment policies.
To fully understand the economic impact of a contract, you will need both the fee schedule and the payor rules such as, (1) payment rules on multiple surgery reductions; (2) timeframes for submission of claims; (3) any contract exclusions; (4) prior authorization requirements; (5) claim submission address; (6) bundling; (7) modifiers; (8) appeal guidelines; and (9) requesting a meet and confer, among other topics in order to get a complete picture of how your claims will be paid.
Payors may use other names for the provider manual, such as procedure manual, administrative manual or pricing/medical policy. You can typically find the provider manual online via the payor’s website and many payors are also publishing their payment and medical policies online as well.
Sample Letter Requesting Your Contract
(Contact Name or Department of Provider Relations)
City, State, Zip
To Whom It May Concern:
This letter is to request a copy of the original signed and executed contract between my practice and your organization.
If changes have been made to the original contract since the date it was executed, please forward a copy of each and every letter/amendment notifying my practice of each modification, including the date that the modification was effective.
Thank you for your prompt attention to this request.