Most commercial payer contracts run 30–80 pages. If you have time for only three sections, read the fee schedule, the claims submission and timely filing terms, and the termination clauses. Almost every real economic dispute between a practice and a payer comes out of one of those three.
The fee schedule: what you are actually being paid
The fee schedule is often attached as an exhibit and stated as a percentage of the current Medicare Physician Fee Schedule — "100% of Medicare," "115% of Medicare," and so on. Before you sign, convert that percentage into real dollars for your top 20 CPT codes using the CMS Physician Fee Schedule lookup (cms.gov/medicare/physician-fee-schedule). Those 20 codes will drive 80%+ of your revenue; if they do not clear your cost per visit, the contract is a loss leader regardless of the headline percentage.
Three fee-schedule details that are often missed:
- Year the Medicare rates are locked to. Some contracts reference "current Medicare" (updates every year with CMS), others lock to a specific year (Medicare rates from 2022 for the life of the contract). The difference over a 5-year term can be material, especially during years when Medicare implements broad cuts.
- Locality. Medicare rates vary by geographic locality. Confirm the contract references the correct locality for your office, not the payer's home office or another state.
- Carve-outs for specific codes. Many contracts pay the stated percentage for most codes but carve out specific codes (preventive counseling, behavioral health, certain procedures) at lower percentages or at fixed rates. Ask for the full schedule, not a summary.
Claims submission, timely filing, and payment terms
Timely filing deadlines are the single most common preventable revenue loss. Commercial payer deadlines range widely: some still allow 365 days from date of service, but many have compressed to 90 or 180 days, and a few require 60. Missing the deadline means the claim is denied with no appeal rights — revenue you earned, gone permanently.
Three things to verify in the claims section:
- Timely filing deadline for initial claims — measured from date of service or date of discharge. Under 90 days is a yellow flag; it means a single office staff vacation or EHR outage can silently cost you claims.
- Timely filing deadline for corrected/resubmitted claims and appeals. These are usually separate (and shorter) than the initial filing deadline. Miss the appeal deadline and a denial becomes permanent.
- Payment terms. Most contracts specify that clean claims will be paid within 30 days (some states mandate this via prompt-payment laws). Confirm the contract does not extend the payment window beyond applicable state law, and that the clean-claim definition is reasonable.
The all-products and silent PPO clauses
Two clauses hidden in the claims section regularly surprise practices after signing. The all-products clause requires you to participate in every product the payer sells — commercial PPO, HMO, Medicare Advantage, Medicaid managed care, exchange plans, narrow networks — at whatever rate the payer assigns to each, often unilaterally. You sign one contract, and you are now in 12 plans with 12 different fee schedules.
The silent PPO provision (sometimes called a "rental network" or "network access" clause) lets the payer rent your contracted rates out to any other payer, employer plan, or TPA without telling you. A claim from an unknown plan shows up paying your contracted rate, and you have no way to opt out.
Both are negotiable. Ask to be in-network only for specifically listed products (list them by name), and strike or carve out the silent PPO / network access language. If the payer refuses, at least ensure you receive written notice of every product you are being added to, and that your rate for that product is clearly stated.
Termination: how you get out
Every payer contract has two termination paths: termination for cause (material breach) and termination without cause. The without-cause terms are what matter most when you want to exit, and the defaults often work against you.
Check:
- Without-cause termination notice period. Typical is 90 days; some contracts require 180. Shorter is better for you. If the payer demands 180 days for both sides, ask for reciprocity.
- Continuing-care obligations. Most contracts require you to keep seeing in-treatment patients at contracted rates for a period after termination (often 90 days, sometimes longer for OB and oncology). This is generally reasonable, but watch for open-ended "until the patient's condition stabilizes" language without any cap.
- Automatic renewal. Nearly every payer contract auto-renews annually unless one side provides written notice of non-renewal within a specific window (often 90–180 days before the anniversary). Note these windows in your calendar at signing — missing the window locks you in for another year at whatever rate is on the exhibit.
- Termination-for-cause cure periods. If the payer claims you materially breached, how long do you have to cure? 30 days is standard; under 15 days is unreasonable. Confirm cure rights apply to both sides.
What to do when the contract is non-negotiable
For the largest national payers, a solo practice has little leverage and the contract is effectively offered on a take-it-or-leave-it basis. Even then, three moves are worth making:
- Document every non-negotiable clause in a one-page "contract inventory" so that when renewal comes up (or when the payer does a roster refresh after an acquisition), you know where your exposures are.
- Ask specifically for the fee-schedule percentage increase or tier change — those are the items most frequently granted to physicians who ask. The silent majority never ask.
- Set a contract review calendar reminder 120 days before each renewal window so you are never surprised by auto-renewal.