Managed care contract negotiation – Preparing to negotiate outline

  • Contracts, manuals & fee schedules, where are they (Oh, my!)
  • Determine payor contract contact
  • Determine if reimbursement is based on RBRVS or compare to Medicare
  • Determination of any billing concerns
  • Analysis of reimbursement data, including full data review vs. top # of CPT codes
  • Prepare gross collection ratio analysis for each payer
  • Determine procedures producing 80% of revenue
  • Prepare areas of leverage/contracting questionnaire
  • Full MCO participation cost review
  • MCO reimbursement comparison top CPT codes
  • Determine unacceptable MCO fee schedules
  • Verify all payor requirements being followed and no practice actions causing issues
  • Prepare list of any payor grievances
  • Prepare list of concerns & how to communicate to payor with deadline
  • Prepare proposal for MCO fee schedules deemed to be less than desirable
  • Determine leverage points and contracting strategy
  • Prepare rationale why payor should provide increases


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