By Marie Paul Turner

A radiology group I worked with last year was collecting on 94% of their claims. On paper, that looks strong. Their office manager was proud of it. Their physicians assumed billing was handled.

But when I sat down and ran a line-by-line comparison of their contracted rates against what payers were actually reimbursing, we found a different story. In 37% of their paid claims, the group was underpaid by a few dollars; in others, by $40 to $80 per procedure. Across thousands of monthly claims, that gap added up to more than $22,000 in monthly revenue they had already earned but never collected.

They were getting paid. They just weren’t getting paid correctly.

This is one of the most common and most expensive problems I see in healthcare revenue cycles, and it’s the one that gets the least attention. Practices obsess over denials, and they should, but underpayments are the silent leak that drains revenue every single day without triggering a single alert in most billing systems.

Over 25 years working across behavioral health, anesthesiology, radiology, gastroenterology, and hospital based services from Broward Health and Tenet/Conifer to NYU Langone Health and Mednax I have negotiated, renegotiated, and disputed more payer contracts than I can count. And the pattern is always the same: practices sign contracts, file them away, and assume payers are honoring the terms. Most aren’t. At least not consistently.

That’s why payer contract negotiation isn’t a one-time event. It’s an ongoing discipline and it’s one of the highest ROI activities any practice can invest in. Here’s the playbook I have built over two decades of doing this work, and the framework we use today at CareSync RCM Billing Experts to help practices stop leaving money on the table.

THE UNDERPAYMENT PROBLEM IS BIGGER THAN YOU THINK

Most practices have no systematic process for comparing contracted rates to actual reimbursements. They trust that when a claim is paid, it’s paid at the right amount. That trust is misplaced.

Payer underpayments happen for several reasons. Fee schedules change and payers don’t always update their processing systems immediately. Modifier-level reimbursement rules get applied inconsistently. Bundling logic varies by payer and by plan within the same payer. And sometimes, payers simply process claims at rates below what the contract stipulates whether by error or by design.

The compounding effect is what makes this so damaging. A $30 underpayment on a procedure you perform 200 times a month is $6,000 in monthly lost revenue, $72,000 annually from a single CPT code. Multiply that across your full procedure mix and multiple payer contracts, and you start to see the scale of the problem.

In specialty environments like radiology and behavioral health, this is particularly acute. Complex modifier requirements, varying place-of-service rules, and specialty specific fee schedules create more opportunities for payer processing errors and more places for money to slip through unnoticed.

WHAT MOST PRACTICES GET WRONG

The biggest mistake I see is treating payer contracts as static documents. A practice signs a contract, maybe reviews it when it comes up for renewal in two or three years, and otherwise ignores it. Meanwhile, CMS updates the Medicare Physician Fee Schedule annually. Commercial payers adjust their methodologies. Your practice’s procedure volume and mix shift. The contract you signed three years ago may no longer reflect the reality of your reimbursement landscape.

The second mistake is not knowing your own data. Before you can negotiate effectively, you need to understand your payer mix, your top procedures by volume and revenue, your average reimbursement per CPT code per payer, and how those reimbursements compare to Medicare benchmarks and to your contracted rates. Most practices don’t have this analysis readily available. Without it, you’re negotiating blind.

The third mistake is accepting the first offer. Payers expect negotiation. Their initial fee schedule proposals are starting points, not final offers. Yet many practices, especially smaller ones without dedicated contract management staff accept what’s presented because they don’t know they have leverage or don’t know how to use it.

And the fourth mistake is failing to dispute underpayments retroactively. Most payer contracts include a window for disputing payment variances typically 60 to 120 days, though some allow longer. If you’re not systematically identifying and disputing underpayments within that window, you’re forfeiting revenue you’re contractually owed.

THE FORENSIC APPROACH: CONTRACT-TO-PAYMENT VARIANCE ANALYSIS

At CareSync RCM, we approach payer negotiations the same way we approach every revenue cycle challenge: forensically. That means starting with data, identifying patterns, and building a case before we ever pick up the phone with a payer representative.

Here’s the framework. Step one is the contract inventory. Pull every active payer contract your practice has. Catalog the fee schedules, effective dates, termination and auto-renewal clauses, escalation procedures, and dispute timelines. You’d be surprised how many practices can’t locate all of their current contracts, or discover contracts that auto-renewed on terms they didn’t realize.

Step two is the reimbursement benchmark analysis. For your top 20 CPT codes by volume, pull 12 months of payment data by payer. Calculate your average reimbursement per code per payer. Then compare those actuals against three benchmarks: your contracted rate, the current Medicare fee schedule, and a commercial benchmark like 120 - 150% of Medicare depending on your market and specialty. This analysis will immediately reveal which payers are underpaying, which codes are most affected, and where your biggest recovery opportunities are.

Step three is the variance report. For every instance where actual reimbursement falls below the contracted rate, document the claim, the expected payment, the actual payment, and the variance. This is your dispute file. It’s also your leverage for renegotiation, because it demonstrates a pattern of contractual non-compliance by the payer.

Step four is the negotiation strategy. Armed with data, you’re no longer asking for a raise, you're holding a payer accountable. For underpayment disputes, submit formal variance reports with supporting documentation and demand payment corrections within the contractual timeline. For contract renegotiations, present your volume data, your benchmark analysis, and a specific fee schedule proposal tied to a percentage of Medicare. Lead with the value you deliver to their network member access, quality metrics, patient satisfaction not just your costs.

One thing I’ve learned across my years negotiating with payers at organizations like Tenet/Conifer and NYU Langone: the practices that get the best contract terms aren’t always the biggest. They’re the most prepared. Payer representatives negotiate dozens of contracts at a time. When a practice shows up with clean data, specific asks, and a clear understanding of their value proposition, it changes the dynamic entirely. You’re no longer a small practice asking for more money. You’re a data-driven partner making a business case. That distinction matters more than practice size in almost every negotiation I’ve been part of.

PRACTICAL STEPS YOU CAN TAKE THIS WEEK

You don’t need a massive project to start recovering underpaid revenue. Here are three things you can do immediately.

First, pick your highest-volume payer and your top five CPT codes with that payer. Pull six months of payment data and compare actual reimbursements to your contracted rates. If you find variances, you’ve just identified your first dispute opportunity.

Second, check your contract dispute timelines. If your window is 90 days, you need a process that catches underpayments within 60 days to allow time for dispute preparation and submission. If you don’t have that process today, you’re almost certainly past the window on recoverable revenue.

Third, calendar your contract renewal dates. Negotiation leverage is highest 90 to 120 days before renewal, because that’s when payers are most motivated to retain providers in their network. If you wait until the renewal notice arrives, you’ve lost your window.

WHERE PAYER DYNAMICS ARE HEADING

The payer landscape is getting more complex, not less. Value-based payment models are layering new reimbursement methodologies on top of traditional fee-for-service contracts. Prior authorization requirements are expanding. And payers are increasingly using AI-driven claim processing that can introduce new categories of payment errors at scale.

For practices especially those in complex specialty environments like behavioral health, substance abuse, and radiology the ability to understand, monitor, and actively manage payer contracts is becoming a core business competency, not an administrative afterthought.

This is the work that drives me every day at CareSync RCM Billing Experts. My co-founders and I built this company because we spent decades watching practices lose revenue to problems that were entirely preventable if someone was paying attention. We dispute underpayments, renegotiate fee schedules, and hold payers accountable for contractual obligations because we’ve seen what happens when no one does.

If you’re not sure whether your payers are honoring your contracts or if your contracts are even competitive that uncertainty alone is a signal worth investigating. CareSync’s Free Forensic Revenue Health Check is designed to surface exactly these kinds of indicators: underpayment risk, payer behavior patterns, and contract gaps. It’s not a full audit and it’s not a sales pitch. It’s a diagnostic conversation that gives you clarity on where the biggest opportunities are, so you can make informed decisions.

DM CHECK or visit caresyncrcm.com to get started. Your revenue shouldn’t depend on whether your payers feel like paying you correctly today.

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