Insights
What Is a Payer Fee Schedule Review and Why Does It Matter?
A fee schedule review compares what payers actually paid per code against contracted rates, revealing underpayments and weak rates to address at renewal.
A payer fee schedule review compares what each payer actually paid per CPT code to the amounts promised in your contract, revealing underpayments and below-market rates. Practices often discover that insurers paid less than contracted amounts or that negotiated rates lag behind regional benchmarks.
How do you compare paid amounts to contracted rates?
You pull remittance data from your practice-management system or clearinghouse, then match each paid line item to the fee schedule or rate table in your signed payer contract. Start by exporting explanation-of-benefits detail for a recent period, group payments by payer and CPT code, and compare the paid amount to the contracted rate.
Steps:
- Export remittance files or EOB summary from your PM or clearinghouse.
- Isolate a single payer and pull the most recent contract addendum.
- Cross-reference each high-volume CPT against the negotiated allowable.
- Flag every instance where the paid amount falls below the contracted rate.
Most practices discover the largest dollar variances in evaluation-and-management codes, procedure codes, and bundled services. Document each discrepancy with the date of service, claim number, and contract clause reference so you can attach proof when you request retroactive payment or renegotiation.
Which codes should you review first?
Focus on your top-ten CPT codes by claim volume and any high-dollar procedure codes that drive the majority of your revenue. Reviewing every code at once is time-intensive, so prioritize the codes that typically account for the largest share of practice revenue. Run a frequency report from your PM system and sort by claim count.
High-priority codes:
- Office visits (99202–99215) and prolonged-service add-ons
- High-dollar procedures (injections, joint aspirations, infusions)
- Behavioral health codes (90791, 90834, 90837) if applicable
- Any code that bundles multiple services or requires prior authorization
Once you confirm those rates are accurate, expand the review to mid-volume codes and any new CPT codes added in recent years. Payers sometimes fail to update fee schedules when the American Medical Association publishes new codes, leaving you with zero reimbursement until you flag it.
| Item | Contracted rate scenario | Paid rate scenario | Action |
|---|---|---|---|
| Office visit code | Rate per contract | Paid below contracted amount on recent claims | File corrected claim with contract excerpt |
| High-dollar procedure | Percentage of billed charges per contract | Paid lower percentage without explanation | Submit reconsideration with EOB and contract |
| New CPT code | Not listed in addendum | Zero payment or bundled incorrectly | Request addendum update and retroactive review |
| Modifier 25 | Full E/M allowed per contract | Reduced or denied | Appeal with documentation of separate service |
What should you do when you find underpayments?
File a corrected-claim or reconsideration request with documentation of the contract language and EOB that shows the shortfall. Most commercial payers accept corrected claims within their timely filing limit. Attach a copy of the relevant fee-schedule page, the original EOB, and a brief letter citing the contract section.
Action checklist:
- Assemble proof: contract addendum, original claim, EOB, and a simple spreadsheet showing contracted versus paid amounts.
- Submit the request within your payer's timely filing limit.
- Track the appeal in a shared spreadsheet or denial-management module.
- Escalate to your provider-relations representative if the payer denies the request without explanation.
Systematic underpayment is leverage for contract renegotiation. If a payer repeatedly pays below contract, present aggregate data at renewal and request either a rate increase or an addendum clarifying the disputed codes.
When should you schedule a fee schedule review?
Complete the review well before your contract renewal date so you have time to document issues and negotiate stronger rates. Most payer contracts auto-renew unless you submit a renegotiation request in advance. Starting your review early gives you time to compile data, file appeals for underpayments, and request rate increases based on benchmarks.
If your practice grew recently—added providers, opened a new location, or introduced new services—run a mid-contract review as well. Volume and mix changes can surface rate weaknesses you did not notice at lower claim counts. An early review also helps you decide whether to add contract language for new CPT codes or modifiers before the next renewal cycle.
How MB Claims handles this
MB Claims performs reimbursement analysis as part of denial management and contract-optimization services. The team compares remittance data to signed contract addenda, flags systematic underpayments, and prepares corrected-claim documentation or appeal letters. When renewal dates approach, MB Claims compiles aggregate variance reports that practices use to negotiate stronger fee schedules with commercial and Medicare Advantage payers. All analysis follows HIPAA protocols and integrates with your existing practice-management system or clearinghouse feeds.
Frequently asked questions
How often should a practice perform a fee schedule review?
Annual reviews align with contract-renewal cycles, but practices that bill high volumes or frequently add services benefit from more frequent spot checks on top codes to catch payment variances early.
Can an outsourced billing company run a fee schedule review?
Yes. Many revenue-cycle-management vendors include reimbursement analysis as part of denial management or contract-optimization services. Confirm they have access to your signed contracts and remittance data before starting the review.
What if you no longer have a copy of the signed payer contract?
Contact your payer's provider-relations department and request the current fee schedule or contract addendum. You may also find rate tables in your credentialing portal or the payer's online contracting platform.
Do Medicare Advantage plans use the same fee schedules as traditional Medicare?
No. Medicare Advantage plans negotiate their own fee schedules, which can differ significantly from Medicare Fee-For-Service rates. Review each MA contract separately and compare paid amounts to the plan-specific fee schedule.
What happens if a payer refuses to correct systematic underpayments?
Document the pattern, notify the payer in writing, and consider non-renewal at the next contract cycle. Some practices also file complaints with their state insurance commissioner if underpayment violates prompt-pay statutes or contract terms.
Outsource medical billing, coding, or credentialing with a HIPAA-aware RCM team. Request a free A/R audit or call (888) 603-5358 to identify underpayments and strengthen payer contracts before your next renewal.
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