Most owners I work with can usually tell me what their reimbursement rates are, at least for their key payers. However, if they need to know when a contract renews, or how many days they have for timely filing of a claim, they’ll have to dig for a copy of the contract in a drawer somewhere, or in an email from whoever handled credentialing three years ago. The contract got read once, right before signing, at the end of a process where the only real goal was to start billing. Nothing since then has forced anyone to open it again.
For this piece I sat down with Adam Williams, who runs Minerva Health Consulting and has spent his career doing payer contracting, credentialing, and revenue cycle work for behavioral health organizations. We talked through how he thinks about the contracting process, what’s most important to look at when reviewing a new contract, especially your reimbursement rates, and how to approach a contract renegotiation.
Credentialing vs. enrollment vs. contracting
If you bill insurance, you have touched this process, probably personally. The first contracts often got signed when the practice was two or three clinicians, somebody filled out the applications at the kitchen table, and the stack has grown one payer and one hire at a time since. So the familiarity tends to be real but thin: the words are recognizable, the mechanics are fuzzy, and the three words that matter get used interchangeably.
They are three different things:
| What it is | Who drives it | |
|---|---|---|
| Credentialing | Your own verification of a provider: license, education, references within their subspecialty, sanctions screenings | You, or a vendor you hire |
| Enrollment | The payer’s process for getting that provider into their system and onto their directory | The payer, working from what you submit |
| Contracting | The agreement that sets your rates and terms | Negotiated between you and the payer |
Enrollment may repeat work your credentialing already did, and the mechanics vary by payer: a PDF, a connection to the provider’s CAQH profile (the shared database where providers keep their credentialing information), a roster, or in a few cases an email. Contracting is what the rest of this article is about.
The timelines are worth knowing because they set your hiring math. “Payers tend to have a 90 to 120 day target to get a provider enrolled,” Adam told me. “The reality of what I see is it could be 180 days plus for a lot of payers.” Groups with delegated credentialing, where the payer trusts your verification process and takes a monthly roster instead of individual applications, can cut that to 30 to 45 days. The usual threshold for delegation is bigger than most group practices: “The sweet spot for most payers is somewhere between 50 to 150 providers to really get delegated.” It’s still worth asking, because some payers set it as low as five providers, and his read is that a specialized group whose credentialing process follows the standards payers recognize (NCQA and URAC, the two big accrediting bodies) can sometimes get there earlier.
Whether delegation is worth researching comes down to your hiring pace. Each standard enrollment can take up to an hour of staff work per payer, on top of the months of waiting; a delegated roster is about an hour a month total, and a new hire starts billing in weeks instead of quarters. The trade is that you own the verification work to an auditable standard, and the payer may audit it yearly. If you’re adding several providers a year, asking your largest payer what their delegation threshold is costs you nothing. If you’re adding one, the standard route is probably fine.
Two cautions on buying help here. First, speed claims: a vendor promising to get a provider credentialed and enrolled in two or three days is not describing how most payers actually work. His realistic floor is that 30 to 45 day window, and only if you are not willing to hold claims. Second, bundling: many billing companies offer credentialing as an add-on, and the cost usually shows up in their percentage rather than as a line item. Adam’s example: a billing service that takes $2.50 out of every $100 you collect, and moves to $6.00 with credentialing added, has more than doubled its cut. On a million dollars of collections that difference is $35,000 a year, for work you can price on its own.
Read the rate section and the contract term first
Adam does not read payer agreements front to back. “The way that I tend to look at agreements is I frankly skip all of it until the rate section first. I start there because that’s ultimately what I care about the most. I want to have an understanding of what’s the term of this agreement and how often can I renegotiate rates. I think that’s often missed by a lot of groups.”
The thing hiding near the rates is the term. “The payer may put in their clause that says this is a three-year initial term. And it may not even be at the top of the agreement. It could be buried somewhere within there. And now you’re stuck with the rates that you have for a three-year period without any increase.”
Here’s why that clause costs real money. Say your rates are locked for three years. Wages go up in each of those years, and you will probably want to give raises before the term is over. The rate stays where it is, so the margin gets thinner each year, and nothing in the agreement lets you do anything about it until the term runs out.
Calculate your rates and make the payer confirm them in writing
Not every contract hands you a fee schedule with dollar amounts by CPT code. Many hand you a formula, and the formula is where owners get surprised. Adam’s move: “I look to see how the rates are calculated. And once I calculate them, one of my first emails back to the payer is, hey, I’ve calculated the rates based upon the formulas you’ve laid out in your agreement, because you didn’t give me the rates for the CPT codes. Can you confirm that what I’ve calculated is accurate?”
Most groups skip this step. They assume the rates will be something, sign, and find out at first payment. “It could be drastically less by the time you get paid, because you missed how they were calculating it.” The email takes ten minutes or so, and it gets the actual numbers in writing before you sign, which is also your paper trail if payments come in low.
How payers present reimbursement rates
Rates show up in one of a few shapes, and each shape has its own question to ask before signing.
| How the rates are presented | The question to ask |
|---|---|
| A fee schedule listing dollar amounts by CPT code | Is every code you bill actually on the list? |
| A percentage of Medicare | Which year’s Medicare fee schedule, and does it update each January when CMS updates, or is it frozen? |
| A formula tied to another index (RVUs, meaning Medicare’s relative value units, or a payer’s internal schedule) | Get the calculation confirmed in writing before signing (the email above). |
The frozen-index problem is easy to miss. A contract that pays a percentage of Medicare sounds like it moves with the market. A contract that pays a percentage of the 2020 Medicare fee schedule does not. Adam’s reaction to that clause: “It’s tied to CMS 2020. Well, that’s great. What does that mean?” It means your rates are anchored to a year that gets further away every January.
One more question worth asking wherever rates are based on the fully licensed clinician: what percentage of that rate applies to your other license levels? If the payer pays less for associate-licensed or mid-level providers, you want that differential in writing, not discovered in your remittances.
Evergreen contracts and annual rate resets
The structure you want is what Adam calls evergreen: an initial term of 12 months, automatic renewal, and rates that reset or become renegotiable every year.
Some payers skip provider-by-provider negotiation and put everyone on market-rate resets, recalibrated annually. His observation is that those usually land somewhere between a 2 and 5 percent increase by code, and the downside is a couple of years where it’s just 2. Groups that renegotiate themselves each year can sometimes do better than 5. Either way, an annual mechanism beats a locked rate. The question for any agreement in front of you: what is the term, and when is my next chance to move the number?
Five payer contract clauses beyond the rates
Adam’s list of the terms with teeth, the ones where the rate is fine and the contract still hurts you:
- Timely filing. “I frankly negotiate timely filing in every one of my agreements,” he said. You will not get 365 days if it is not already there, but you do not have to accept a 60 to 90 day window. A short filing deadline also compresses your window for appeals and denials.
- Indemnification. Understand who is covering whom before you sign, not during a dispute.
- Dispute resolution and payer insolvency. If it goes wrong, is it arbitration or court? And what happens to money you are owed if the payer goes bankrupt?
- Governing law and venue. “It may be great that the payer wants to use Delaware, but is Delaware a friendly state for your MSO or your group?” (An MSO is a management services organization, the entity some practices run their business operations through.) Check which state governs the agreement before you ever need to know.
- Your own entity data. Legal name, tax ID, group NPI, all exactly right. “I’ve seen some groups sign their agreements under their DBA.” Check the signature page against the legal entity you actually bill under today.
How to benchmark your reimbursement rates
Price transparency rules were supposed to make everyone’s rates public. Adam’s honest assessment: “It’s more on the theoretical availability today than it really is truly publicly available.” Payers are inconsistent and late with the data, and the raw machine-readable files are not something a practice owner is going to parse on a weekend.
The practical substitutes, in the order I’d try them:
Benchmark against Medicare. “Medicare should be your target baseline for a lot of services,” he said. Work out what percentage of Medicare each payer is paying you. Asked whether mental health rates typically sit above or below Medicare, his answer was that it is all over the map, it depends on the region, and some commercial rates are even tied to an area’s Medicaid rates. There’s no national number to compare yourself against, so the percentage-of-Medicare view is the one that travels: it puts every payer on one scale.
Ask an AI assistant. “Having access to ChatGPT and Claude to dig around a little bit and prompt, and try to pull your geographical averages, it actually does a fairly good job of starting to find what an average provider in your area is getting. It’s not to the depth that you’re going to get in the price transparency data. But it gets a good average.”
Buy a one-time data pull. Price transparency vendors are built around subscription pricing, which makes sense for larger organizations but doesn’t always fit a small practice’s budget. The good news: in his experience, many of these vendors, like Turquoise Health, Serif Health, and Trek Health, will meet a small group in the middle with a one-time pull, scoped to your geography and top five payers, for a flat fee.
How to ask a payer for higher rates
A renegotiation starts before anything goes to the payer. The timing comes out of the contract itself: the renewal window you found in the term section is when the door is open, and outside it you are mostly waiting. The grounds come out of the benchmarking above. An ask that says “this contract sits 15 percent below my other agreements” or “20 points below where this region runs against Medicare” gives the payer’s rep something they can carry to their own side. “We’d like more” does not.
The other half of the prep is knowing where the rate needs to be for your practice, not just where it sits against the market. It’s the same margin math I walk owners through in the gross margin guide. Take your average reimbursement rate for a payer. Multiply by the sessions a clinician actually delivers. Put that against what the clinician costs you fully loaded. That tells you which payers work at your comp structure and which don’t, and it turns a renegotiation target from a wish into a number.
Whether the ask lands depends on your position, and Adam is straightforward about what the position rests on. A group that covers most of a specialty in its geography has clout from volume alone. Most therapy practices are not in that spot, and his advice for everyone else is to make the case on quality and access. On quality, that means measurement-based care: “Having clients fill out these measures, having your providers fill out these measures, help to ensure that you are able to prove to the payer that there’s a value add in your services.” On access, keep your panel open: “The more often you close your door to that payer, it’s indicating that they can’t trust that you could take referrals, and so they’re not going to want to pay you more for those services.” Extended hours, weekend availability, and after-hours coverage sit in the same bucket. His summary of the pattern: the more your group runs as a well-managed service for the payer’s members, the more likely the payer is to pay for it.
Sometimes the ask is the whole strategy. One practice I work with was quoted initial rates on an Evernorth contract that came in well below their other agreements. We requested a higher rate, in line with what they held elsewhere and with their capacity to serve that population, and Evernorth came back with a revised, higher schedule. That is one case, and I would not promise it repeats everywhere. But the cost of asking was one email, and the alternative was locking in the low schedule for the life of the term.
How many payer contracts you should hold
More contracts is not automatically better. Every line of business you add (commercial, then Medicaid, then Medicare) adds contract surface: managed care organizations, Medicare Advantage plans through the commercial payers, each with its own enrollment path, filing deadlines, and renewal calendar. That administrative load lands on the same office manager who is already doing three jobs.
Adam’s starting heuristic is simple: know who your top three payers are, and how many covered lives you think they represent in your geography. Be intentional from there. The administration is the same whether a contract sends you forty patients or four.
Six things to check in your top three payer contracts
Pull the agreements for your top three payers this month. If nobody can find one of them, that is finding number zero, and requesting a copy from the payer is the first step. For each contract, find:
- The term and renewal. Initial term length, auto-renewal, and the date of your next renegotiation window. Put that date on a calendar.
- The escalator. Any annual adjustment mechanism, and what it’s tied to. If there is none, your rate is flat until you act.
- The rate basis. Fee schedule, percentage of Medicare (which year?), or formula. If it’s a formula, calculate it and send the confirmation email.
- Timely filing. The number of days, and whether your billing operation reliably files well inside it, with room left for corrections and resubmissions.
- Governing law and dispute resolution. Which state, arbitration or court.
- The entity on the signature page. Legal name, tax ID, and NPI, matched against what you actually bill under today.
An owner who does this for three contracts will know more about their payer agreements than they learned in the past three years, and will usually come away with at least one date or one number that needs acting on.
About Adam Williams
Adam Williams started Minerva Health Consulting to close a gap he saw too many healthcare startup founders fall into: waiting until mid-launch, when the payer landscape is already costly to navigate, to figure out their strategy.
With 15+ years in payer contracting, credentialing, and revenue cycle management, Adam helps digital health and behavioral health founders build a payer strategy that actually holds up, from network entry and credentialing to contracting and reimbursement. His goal isn’t just to solve the immediate problem; it’s to help founders build the operational foundation that lets them scale with confidence.
Learn more at minervahealthconsulting.com.
About Eastfield Consulting
Eastfield Consulting provides fractional CFO services to therapy and ABA practices. Its founder, Jonathan Bunjer, built and sold an EMR/RCM company, then led revenue cycle management at a major health tech company, before serving practices directly. If the read-through above surfaced a date or a number that needs acting on, the practice revenue check-up is a fifteen-minute way to see what a CFO would look at first, or you can book an intro call.