Percentage raises from payers don't say what each code pays

Ask the payer for the new fee schedule. If the payer won't send one, send a chart of your codes and ask for each rate back in writing.

Nate Peereboom
Co-founder, JotPsych

Your payer offers your practice a 4.9 percent increase by email.

Four steps to each new rate

1. Ask for the payer's fee schedule. Ask for each code's new rate. Then check each one against the rate you're paid today. Payers sometimes "give you less than what you already have," said Doral Jacobsen, who runs a payer contracting firm. She answers a percentage raise with "On what?"
2. Send a chart if the payer won't share its fee schedule. Ask for the chart back with each new rate confirmed in writing. Jacobsen's fallback is a chart of "the CPT codes, and exactly what you calculated," sent "for confirmation," because without confirmation, she said, "you are in great danger."
3. Keep each code's charge above its new rate. Medicare pays the lesser of your actual charge and the fee schedule amount. If your contract has the same term and your charge sits below the new rate, the payer pays your charge, not the new rate.
4. Check the first payment after each rate change. Payers sometimes pay you the new rate in year one, then "never turn the rate on" in year two, Jacobsen said. "This happens a lot." Payers won't "make up for three years of paying you incorrectly." Aetna and Cigna each limit the time you have to dispute a payment.

Cigna says state mandates or your contract can change its dispute process. For a payer other than Aetna or Cigna, look up its time limit to dispute a payment. Start with the payer that offered your last raise. Ask for its fee schedule.