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Negotiating Higher Reimbursement Rates

Most practices sign the first fee schedule a payer offers, and payers count on it. But contracted rates are negotiable more often than clinicians assume, especially for specialists, undersupplied specialties, and practices in coverage-gap geographies. This guide covers when you have leverage, what to ask for, how to build a request a contracting department can act on, what happens after you send it, and how a success-fee negotiation works.

Why the First Offer Is Rarely the Best Offer

A commercial payer's standard fee schedule is designed to be signed without discussion. It is usually expressed as a percentage of a Medicare fee schedule from a specific year, and that year is often several years old, which means the rate stays flat while Medicare's own schedule and your costs move. A contract that looked reasonable when you opened your practice may pay noticeably less in real terms five years later without a single line having changed.

Contracting departments do have discretion. They work from a standard schedule but they also carry a list of exceptions approved for practices the network needs. Getting onto that list requires asking, in writing, with numbers.

When You Have Leverage

At initial contracting, before you have signed, at renewal windows, when your specialty is scarce on their panel, and when you can document rates from comparable payers. The worst time to negotiate is never: rates quietly erode against inflation every year you do not look at them.

• Initial contracting. You have not agreed to anything yet, and the plan has already decided it wants you in the network or it would not have sent a contract.
• Renewal and anniversary dates. Most contracts specify a window, typically 60 to 90 days before the anniversary, in which either party can propose changes.
• Network adequacy. If the plan is short on your specialty in your county, or its members are driving past your office to reach an in-network provider, that gap is your leverage and the plan's provider relations team already knows about it.
• Comparable rates. If another payer in the same market pays more for the same codes, that is a fact the contracting department can take to its own management.
• Practice changes. Adding a provider, a service line, extended hours or a second location changes what you offer the network and is a natural reason to reopen the conversation.
• Volume. A plan whose members make up a large share of your panel has more at stake if you leave the network than a plan that sends you a handful of patients.

What to Actually Ask For

Target your highest-volume codes, not the whole schedule; ask for percentage-of-Medicare benchmarks rather than vague increases; and get the final schedule in writing before countersigning. A few points on your top ten codes is often worth thousands per provider per year, recurring, not one-time.

The specific asks that get results share a form. They name codes, they name a benchmark, and they name a number. Compare a request for a fair increase, which a contracting analyst cannot act on, with a request that codes 99213, 99214 and 99215 be paid at a stated percentage of the current-year Medicare physician fee schedule. The second request can be modeled, escalated and approved.

• Your top ten to fifteen codes by revenue, which in most practices account for the large majority of collections
• A stated percentage of the current Medicare fee schedule, and the word current matters because it means the rate updates each January
• A carve-out for any code the plan pays unusually poorly relative to others
• Removal of any clause that lets the plan change the schedule unilaterally without notice
• An effective date for the new rates and confirmation that claims from that date will be reprocessed if the amendment is signed later

Building the Request

The work before the conversation is what decides the outcome. Pull 12 months of claims for the payer and sort by allowed amount times volume. Take the top codes, look up the current Medicare rate for your locality, and calculate what percentage of Medicare the plan is paying you on each. Do the same for two or three other payers. The spread between them is the first page of your request.

Then add what the plan cannot see from claims. Access measures such as same-day availability, extended hours and telehealth. Cost measures such as low emergency department use or generic prescribing. Quality measures if you report them. A specialty or language the network lacks in your area. Any of these can turn a rate request from an expense the plan is being asked to absorb into a network improvement the plan is being asked to fund.

Send the request to the contracting or provider relations contact named in your agreement, not to the general provider services line. Ask for a written response by a date. Keep every email.

What Happens After You Send It

Expect a slow response. Contracting departments are small and rate exceptions go through a review that typically takes several weeks. Follow up on a schedule; PECS follows up regularly and records each contact. If the plan asks for more data, provide it quickly. If the plan offers less than you asked, calculate what the offer is worth over a year before deciding; a partial increase that recurs is usually worth taking while you continue to work on the rest.

When the plan agrees, the change arrives as a contract amendment or a new fee schedule exhibit. Read it against your request. Confirm the codes, the percentage, the benchmark year, the effective date and the term. Only then countersign. Then check the first month of claims after the effective date against the new schedule, because rate loads into a payer's claim system are a separate step and they are sometimes missed.

Mistakes That Cost Practices Money

• Signing the initial contract to start seeing patients sooner, with a plan to renegotiate later. Later rarely comes, and the plan now has a signed schedule to point to.
• Asking for a percentage increase on the whole schedule. It is easy to refuse and hard to model.
• Accepting a percentage of a fixed-year Medicare schedule, which freezes the rate.
• Negotiating by phone with nothing in writing.
• Not checking that the new rates were actually loaded.
• Never looking at the schedule again after signing.

Rates for New Practices and for Credentialing Clients

The initial contract that arrives after credentialing is the best negotiation window most practices will ever have, and it is the one most often wasted because the practice is focused on getting live. If PECS is handling your credentialing, the contract review at the end of each commercial application is the point where the fee schedule gets a first look. Where a schedule is clearly below market for the specialty and area, the negotiation can start before the contract is signed.

How the Success Fee Works

The fee is per payer, not per code, and there is no charge when a plan declines. The work includes the claims analysis, the written request, submission to the right contact, regular follow-up, and review of the amendment before you sign. Practices can see the status of each negotiation by reference number at pecs.health/status.

Frequently Asked Questions

By the PECS credentialing team, updated September 22, 2026.