Changes in the economics of healthcare have made managed care contracts more important than ever. Physicians can no longer simply trust that they’re being paid fairly and accurately according to the contracts they signed.
The reimbursement rate is only one piece of the puzzle. Contracts also define which benefits are covered, stop-loss provisions, incentives, and how members are counted and allocated. They’re legally binding documents that deserve careful review, yet many physicians sign them without challenging or negotiating rates. Contracting isn’t a one-time event either. It calls for an annual analysis of your top payers: the current reimbursement rate, the volume of encounters, and the revenue each payer brings in.
We rebuilt the billing workflow for a failing surgical center that was drowning in denials and missing documentation. By fixing coding errors, clearing old A/R, and stabilizing submission processes, revenue more than doubled within five months.
An annual review of your top payers is a good baseline, looking at contracted rates, encounter volume, and revenue by payer.
By comparing what each payer actually paid against the contracted rate for your highest-volume codes, which often reveals payments below contract that no one flagged.