Physician reimbursement is one of the biggest areas of frustration for practice owners. Ongoing rate declines, coupled with increased overhead and regulatory changes are demotivating for physicians and administrators.

There is however, a light at the end of this tunnel. Physicians Practice first began surveying practices in order to determine average commercial reimbursement rates over ten years ago. The 2014 survey indicates small payment increases for new and established patient visits.

Celebrating? Not so fast. Experts caution that regardless of the survey findings, traditional fee-for-service reimbursement is most likely to continue declining over the next several years.

Where is the silver lining? Many of the changes are happening on the reimbursement side, and while change may be uncomfortable, change can also bring forth new opportunities. For your practice, preparation is key in order to successfully take advantage of these changes.

To get your practice onto the right path, here are a few ways in which your practice can make the most of its current payer contracts and capitalize on the changing reimbursement environment.


As health reform takes the place of the current healthcare landscape, more of the payers are changing their contracts with practices. Practice managers really need to pay attention to the details. The more you know about upcoming contract changes, the more prepared you will be to deal with them. Some examples are, payment adjustments and  moving to a different Medicare base year. With better preparation you will have more time to fight these coming changes, if necessary, before they go into effect. Change your mindset from thinking that occasionally something might pop up, to thinking and expecting that everything you know about healthcare is changing.

Keep a close eye on your EOB statement (explanation of benefits) as well as your electronic remittance advice reports. Don’t chalk up a simple movement in the report to a change in the patient’s plan or assuming something went to the deductible. Follow up with the payer and find out if something has changed.


To ensure that the terms of the contract still work for your practice, conduct an annual audit of your practices’ contracts. A typical scenario often seen amongst practices is the addition of a service in  your practice. This service was not part of the original contract, or the cost of the service may have suddenly jumped and the payment you are currently receiving is not matching up to your service cost. When these issues occur, reach out to the payer and try and work out a suitable solution.

As a supplement to the annual contract audits, keep a close eye on the accuracy of your payments. If you haven’t already, load your fee schedules into your practice management system so that you can confirm whether the payments align. Leaving money on the table is typical for practices who are not vigilant. Payers do make mistakes. Having this expectation in mind can help you to focus on ensuring your fees are being paid.


While auditing your payer contracts, consider how plans that have been purchased through the health insurance exchanges could have an effect on your reimbursement What does that look like? If you have been excluded from one of your payers’ exchange plans, consider whether inclusion could boost your reimbursement. Keep in mind that while rates in exchange plans are typically 20% lower than rates in in HMO plans, there will be some circumstances where your practice may find inclusion beneficial; One example would be if many of your established patients are now insured through that plan. If you want to get added to a plan, contact your payer for options.

For additional information or for help with physician billing services

Contact AUDX MD  for a free consultation  1-800-875-8765

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