CC Services QA: Your No-Nonsense Guide to Payer Contracting
Where Do I Start?
Let’s start with your strategy. We have to decide who you want to get in-network with and why!
Should I Take Medicare?
Medicare is a major government payer serving largely the 65+ age range. So, if you’re serving a population even partially over 65+ in age, it is highly recommended to obtain a Medicare contract. Medicare contractors (the company that administers the benefits, claims processing, etc.) vary by region, so potentially by state.
Should I Take Medicaid?
Medicaid is run state by state. So, every state is different. That said, Medicaid also covers a large population of patients and is really a necessity for certain service lines where the demographic may be more prevalent, such as Suboxone treatment. Medicaid does typically pay less than most/all payers though; roughly $0.70 on the dollar.
Who Are the Big Commercial Payers?
The “Big 5” national companies are Aetna, BlueCross, Cigna, Humana and UHC. Typically BlueCross and United Healthcare will represent the largest portion of your patient base – as much as 60-70% in certain situations. Aetna and Cigna may make up 5-10% each as well. Humana has traditionally been a major payer, but has more recently retreated largely into the Medicare Replacement markets.
What’s Medicare Replacement?
Certain commercial payers will offer Medicare Replacement Policies (MRP), where the commercial payer, for example UHC, will administer the Medicare benefits. These plans often have “fancy” names like Medicare Advantage, etc. We ALWAYS enroll our practices for the Medicare Replacement Networks if we are going for the commercial payer as well as Medicare. There is no additional cost for this service.
Does Medicaid Have Replacement Policies?
Yes. Similar concept to above. Medicaid also has what are called Managed Care Organizations or MCOs. These are specific to certain states, and again vary by state because Medicaid is a state run program. Some states have MCOs that run the entire program, meaning you bill them and NOT Medicaid. Others will have the MRPs.
If you’re enrolling for Medicaid in a state with MCOs, you’ll need to enroll with Medicaid to get a Medicaid ID as well as each of the MCOs, and these are separate applications which carry separate costs.
What About Local Payers?
Every region is different as is every state, but we will often make recommendations on local payers that may suit the practice’s strategy. There are also national payers that are “smaller” in terms of total lives covered such as Tricare, Multiplan, etc.
So How Do I Decide What I Need/Want?
Start with budget and the concept of a “critical mass.” If you’re paying for marketing, but only marketing to a small subsegment of the market because you’re only taking a few plans…your marketing dollars are not going to go as far!
So, we suggest NOT limiting your initial contracts to save a few hundred bucks when you’re going to be spending thousands on marketing month over month.
So…Your Thought Process Might Look Like This:
- Am I taking Medicare Y/N (recommended)?
- Am I taking Medicaid Y/N (recommended especially for Suboxone)?
- Do I want to take the Big 5 Y/N?
- If not taking Medicare/Medicaid → go broader on commercial plans.
- If skipping the Big 5 → at least take BlueCross and UHC. Then consider Aetna/Cigna. Then Humana.
- Do I want to take Local Payers Y/N? (We’ll guide you here.)
- Do I want to take MRPs Y/N? (Always yes – no cost, broader reach.)
How Much Will I Get Paid?
Generally speaking, contracts are rough these days. Unless you are in a rural area and/or in a state without major metro areas like NYC, Chicago, LA, Miami, Atlanta…you should expect your contracts to be within 5–10% of Medicare rates.
In Florida or California? Take a deep breath. Expect as low as 70% of Medicare with “network saturation” (aka “we have too many providers like you, try again in 6 months”). On the flip side, North Dakota and Wisconsin might give you 150–180% of Medicare.
Do You Negotiate Rates?
Unfortunately not. We always ask, but most payers respond with the polite equivalent of “kick rocks.”
There are companies that ONLY negotiate rates (not contracts) but they charge $15K–30K+ and take 12–18 months. That’s why we don’t sell it. If you’re interested, we can introduce you to the few good ones we know.
What If I Want to Service Clients in Multiple States via Telehealth?
You can do that! But…know the rules:
- Some states require live visits within certain timeframes.
- You need a license and office address in each state.
- Casting too wide of a net will directly impact your pricing.
What If I Don’t Have an Address?
Not a service we offer, but plenty of providers out there can help.
What If I Don’t Have a License?
You cannot practice or begin the credentialing/contracting process without it.
What’s a Group NPI (GNPI) and What If I Don’t Have One?
A GNPI is assigned to your business rather than you as an individual. Best practice is to assign contracts to your group, which allows scalability, flexibility, and protects your income.
If your contracts are tied to your individual NPI, you can’t add new providers and you risk lower payments if you’re moonlighting elsewhere.
OK, But I’m Contracted as an Individual?
Rework those contracts. Yes, it’s annoying and not free, but worth it long-term.
How Much Does This Cost?
We charge $250 per provider, per state, per panel (company).
Formula:
Provider count x State count x Panel count x $250 = Total price
Example: 1 provider in 1 state with 5 panels = $1,250.
How Long Will This Take?
3–6 months is a safe estimate. Could be faster, could be slower. It depends on you (getting us info fast) and the payers (who move like sloths on vacation).
Why Use Us?
Because we:
- Communicate constantly (weekly/biweekly harassment of payers is our love language).
- Respond within 24–48 hours.
- Deliver actual documentation (not just “you’re good to go” emails).
We can’t make this painless, but we make it less of a dumpster fire.
