Credentialing
Payer Contracting and Insurance Contract Negotiation Services
Insurance contract negotiation services have to cover more than rates: a 2019 CAQH survey of 1,240 physician practices counted 20.2 health plan contracts per practice on average, each with its own fee schedule, filing limit, renewal date and exit terms.
The short answer
What do insurance contract negotiation services cover?
More than the rate: check each contract's fee schedule, lesser-of clause, timely filing limit, overpayment recovery, termination and renewal terms. An insurer has 20 days to pay an electronic claim or notify a denial or contest, and no contract can waive that (s. 627.6131(10)). The Advixor Group flags the operational terms that affect cash flow and workload, supports the negotiation and tracks each contract's renewal date.
SourcesAMA, Payor Contracting 101s. 627.6131, Florida Statutes
Contract terms
Payer contract management: the terms to check
In healthcare contract management, commercial and managed care contracts come down to the terms below, and Florida law sets a floor under several of them.
| Term | What to look for | The floor in Florida or federal law |
|---|---|---|
| Rate basis | The plan’s own schedule, a % of current-year Medicare, or a fixed past year | Negotiated |
| Fee schedule | The full schedule for the codes you bill | HMOs must disclose it to physicians, chiropractors, podiatrists and dentists, with 30 days’ notice of changes |
| Lesser-of clause | Pays the lower of your charge or the contract rate | Medicare’s own rule (42 CFR 414.21) |
| Timely filing | The contract’s limit, against the statute | Florida: within 6 months of service, or of getting the correct insurer details; Medicare: 1 year |
| Overpayment recovery | The look-back period; notice before an offset | 30 months (12 for physicians, chiropractors, podiatrists and dentists, among others); no offset without a written agreement or your failure to respond |
| Termination | Notice without cause; a cure period | HMOs: 60 days each way, copied to the Office of Insurance Regulation, plus a written reason when the contract is with a physician, chiropractor, podiatrist or dentist; Medicare Advantage: 60 days |
| Amendments | Mutual written consent, or one-sided with notice | Set by the contract (AMA sample clauses: a 45-day amendment notice, labeled favorable to payor; a 90-day manual-change notice, labeled favorable to physician) |
| All products | Being required to join the plan’s other products | Void, Medicare and Medicaid products included, unless your group negotiated the contract |
| Exclusivity | Limits on contracting with other plans | Barred in HMO contracts |
| Lowest rate | A promise to give the plan your lowest rate | Flagged in the AMA checklist |
| Renewal | Automatic renewal while rates change quietly | Flagged in the AMA checklist |
Sources ss. 627.6131, 627.6474 and 641.315, F.S. (2026); 42 CFR 414.21, 422.202(d)(4) and 424.44; AMA, Payor Contracting 101 (2021), pp. 3–6.
Rate basis
Healthcare payer contract negotiations start with the rate basis
MGMA’s first step: for each top payer, list the CPT codes that drive 80% or more of your revenue and compare the rates code by code, taking them from the payer or from your EOBs. For physicians, chiropractors, podiatrists and dentists, s. 641.315(4)(d) lets an HMO send its complete schedule electronically, or a written copy if you request one.
A schedule tied to current-year Medicare moves every January with the conversion factor: $32.35 in 2025, $33.40 in 2026 (+3.26%; $33.57 for qualifying APM participants), and $32.63 for 2027 under the final rule (−2.31%; $32.95, −1.83%, for qualifying APM participants) as 2026’s one-year 2.5% increase expires. A contract priced at a percentage of current-year Medicare loses that 2.31% on January 1 before any change in a code’s RVUs, while a fixed-year schedule stays put. Lesser-of clauses cut the other way: when your charge is below the allowed amount, your charge is all the plan pays, so check your own fee schedule against each contract’s rates.
Prompt pay
Florida prompt-pay rules that health insurance contract negotiations can’t change
Florida sets these clocks for insurers’ major medical policies, PPO and EPO policies included (s. 627.6131), and the same ones for HMOs (s. 641.3155).
An overdue payment bears simple interest of 12% a year, and a plan can’t retroactively deny a claim for patient ineligibility more than 1 year after paying it. Secondary claims are due within 90 days of the primary plan’s final determination. Medicare Advantage contracts must carry a prompt-payment term (42 CFR 422.520(b)), and Florida’s Medicaid health plans must pay 98% of clean claims within 20 days under their AHCA contract.
“The provisions of this section may not be waived, voided, or nullified by contract.”
Sources s. 627.6131(4)–(5) and s. 641.3155(3)–(4), Florida Statutes (2026). Read Oct 2026.
Disputes
Overpayments, underpayments and disputes under payer contracts
- 40days to pay, deny or contest an insurer’s claim for money back, and 35 days to give written notice of a contest.
- 12months from payment for your own underpayment claims, as a physician, chiropractor, podiatrist or dentist, to reach the insurer.
- 60days for a plan’s internal dispute process to end. While a denied claim sits in it, you can’t pursue the patient for covered services.
- 12months from the plan’s final determination to file with AHCA’s claim-dispute program, which hears contracted and non-contracted providers. Your contract may require the internal process first.
Sources s. 627.6131(6) and (19) and s. 408.7057, Florida Statutes (2026).
Our service
How our healthcare payer consulting works
We compare each offer’s rates for your most-used codes with the Medicare fee schedule and your other contracts, negotiate with the plan on your behalf, and send the final contract to your attorney before you sign. Our fee depends on the plans and providers involved: we go over your needs first and quote it in writing. Contracting depends on each plan’s requirements and approval, and we don’t guarantee participation or reimbursement rates.
Payer contracting
- We flag the operational terms that affect cash flow and workload: timely filing, claims rules, offsets, renewal and termination.
- We support the negotiation and track each contract’s renewal date, so you can reopen terms in time.
What’s included
What our insurance contract negotiation services include
Payer enrollment
Applying to each plan's network, the step that comes before any contract.
Learn moreRecredentialing
The recredentialing cycles and change reports every network contract requires.
Learn moreFlorida Blue and BCBS
Florida Blue and BCBS: how participation and credentialing work.
Learn moreUnitedHealthcare and Optum
UnitedHealthcare and Optum: credentialing first, then the contract.
Learn moreFlorida Medicaid plans
How the Florida Medicaid health plans in your region credential and contract.
Learn moreOther payers
How Tricare, Devoted Health and other payers handle participation.
Learn moreQuick answers
Insurance contract negotiation services: what to know before and after you sign
What payer contracting is, how to negotiate and when to renegotiate, pay while credentialing is pending, and self-funded employer plans. Bring your own contract questions to a consultation.
What is payer contracting?
How do you negotiate a payer contract?
When can I renegotiate a payer contract?
Does a plan have to pay me while my credentialing is pending?
Do Florida's prompt-pay rules cover self-funded employer plans?
Talk to an advisor
You care for patients. Who’s taking care of the business?
Tell us where your practice is today. We will tell you what we would do first.
Official sources
- Florida Statutes (2026), read Oct 17 and 19, 2026: ss. 627.6131 (prompt pay, insurers), 641.3155 (prompt pay, HMOs), 627.6474 (all-products clauses), 641.315 (HMO provider contracts) and 408.7057 (claim disputes)
- eCFR, read Oct 17, 2026: 42 CFR 414.21 (lesser-of), 422.202 and 422.520 (Medicare Advantage), 424.44 (Medicare timely filing)
- CMS: CY 2026 physician fee schedule final rule (Oct 31, 2025) and CY 2027 final rule (Nov 4, 2026) fact sheets; 91 FR 70992. Read Oct 17 and 19 and Nov 11, 2026
- AHCA, SMMC Model Health Plan Contract, Attachment II (July 2026). Read Oct 17, 2026
- AMA, Payor Contracting 101 (2021); MGMA, contract rates tied to the Medicare fee schedule (Jan 14, 2019); DataSpring (formerly CAQH), practice survey whitepaper (survey Sept 2019). Read Oct 15 to 19, 2026
- Health plans: Aetna, joining the network; UnitedHealthcare, Join our network; Cigna, Credentialing. Read Oct 15 and 17, 2026