Happy Valentine’s Day from Berkeley and Associates! Why are we making our Valentine’s Day newsletter about contracts? Because just as strong and lasting relationships are built on clearly communicated expectations, contracts are only strong and beneficial if the language is clear. Here are some rules of thumb to help you evaluate your contracts.
Are you sure your contracts are working for you? Could your reimbursement be affected by one-sided contract language? Here are 8 simple tools to review to help you evaluate your contracts:
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Who Is Contracted? Who is the legal entity being paid?
Key point: The contract must clearly state which entity is paid (Group, Facility, Individual)?
Why it matters: The wrong TIN/NPI or missing NPI = unpaid claims or future recoupments.
Recommendation: Confirm legal entity name, TIN, billing NPI(s), rendering NPI(s), and locations are correct and complete. All providers that should be paid under the practice should be added to the contract with an NPI.
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What Services Are Covered
Key point: If a service is not contractually covered, it is not payable, even if medically necessary.
Why it matters: Missing CPTs = routine denials and write-offs.
Recommendation: Require explicit inclusion of professional vs. facility services and specialty scope. If this is a new unfamiliar contract, share a list of CPT codes and ask their fees and how they are covered.
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How You Are Paid
Key point: Never rely on “standard rates” or “per policy.”
Why it matters: Lack of transparency leads to chronic underpayment.
Recommendation: Fee schedule must be attached or clearly defined (e.g., % of Medicare with year reference).
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Medical Policy Control
Key point: Plans can deny care retroactively using updated policies.
Why it matters: Policy changes = revenue loss after care is delivered.
Recommendation: Limit retroactive application of new policies.
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Overpayments & Recoupment
Key point: Plans often define overpayments broadly and look back indefinitely.
Why it matters: This is the #1 cause of unexpected revenue loss.
Recommendation: Cap look-back periods and require provider notice and appeal rights.
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Silent PPO / Network Leasing
Key point: Your discounted rates may be accessed by entities you never agreed to.
Why it matters: This quietly erodes revenue with no increase in volume.
Recommendation: Require disclosure and opt-out rights.
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Term & Termination
Key point: Short termination notice = sudden revenue shock.
Why it matters: Providers need time to transition patients and contracts.
Recommendation: Minimum 90-day termination without cause.
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Changes to the Contract
Key point: Many contracts change without signatures.
Why it matters: Your economics can change overnight.
Recommendation: Require advance notice and right to terminate if changes are adverse.
Suggested Contract Language (Provider-Protective)
Here are some additional tools, you can use or adapt the language below when negotiating a contract.
Silent PPO / Network Leasing (Suggested Language)
Provider’s contracted rates may not be leased, assigned, or otherwise made available to third parties without Provider’s prior written consent.
Any approved downstream entities must be disclosed in writing, and Provider retains the right to opt out upon notice. The network used to allow a discount must be disclosed on the member card or EOB. Discounts should not be allowed from non-contracted payors and payment should be considered in network for the provider.
Why this works: Prevents hidden discounting.
Initial Term & Renewal (Suggested Language)
The initial term of this Agreement shall be three (3) years, followed by automatic one-year renewals unless terminated in accordance with this Agreement. Suggest cost of living incremental adjustment after year one.
Why this works: Stability for planning and contracting leverage.
Amendments & Policy Changes (Suggested Language)
Material amendments, including changes to reimbursement or medical policy, shall require at least sixty (60) days’ advance written notice.
Providers may terminate the Agreement without penalty if such changes materially and adversely affect reimbursement.
Why this works: Stops “policy by portal posting.”
Negotiating Fees (Practical Language Providers Can Use)
Medicare-Based
Provider requests reimbursement at [X]% of the current Medicare Physician Fee Schedule, updated annually.
If Rates Are “Non-Negotiable”
Request alternative rate structures, case rates, or targeted CPT adjustments based on specialty. Review for cost.
Why this works: Keeps negotiation professional, data-driven, and non-confrontational.
We’re here to help!
These are confusing times for providers and medical groups. In this ever-shifting ecosystem of hidden compliance and unknown requirement, we would love to help. Please reach out with any questions or comments to [email protected] or call our offices at 405-849-4016.
