Proactive Rate Increase Request

[Practice Letterhead: Name, TIN, NPI(s), Address, Phone]

[Date]

[Payer Contracting Manager Name and Title]

[Payer Name]

[Payer Address]

Re: Request for Fee Schedule Renegotiation
Provider: [Legal Entity Name]
TIN: [Tax Identification Number]
Agreement: [Agreement Name / Contract ID]
Effective Date: [Current Contract Effective Date]

Dear [Contracting Manager Name],

Opening: Relationship and Book of Business

[Practice Name] has served [Payer Name] members since [Year relationship began]. We provide care to approximately [Number of payer members seen annually] of your members each year at [Number of locations] locations in [Market/Region]. Our team includes [Number] physicians and [Number] advanced practice providers who serve members enrolled in [Products/LOB covered, such as Commercial PPO, HMO, or POS].

We value our relationship with [Payer Name] and are requesting a formal review of our commercial fee schedule. Our current reimbursement does not appear to reflect our position in the market, the services we provide to your members, or the rates paid to comparable providers for the same services.

Market Evidence: Where We Stand

We reviewed publicly available Transparency in Coverage data for our service area. The findings are summarized below and documented in the attached benchmark report.

Current Market Position: Top [Number, such as 20] CPT Codes by Volume:

Summary:

• Our weighted average reimbursement across these codes is at the [Weighted Percentile]th percentile of in-network rates in [Market/Geography].
• Our effective rate is [Aggregate % of Medicare]% of current-year Medicare, compared to a market median of [Market Median % of Medicare]% for comparable providers in [Specialty/Taxonomy] in this market.
• The total annualized reimbursement gap on these codes alone is approximately $[Total Annual Gap].

[IF APPLICABLE: Gap-Fill Erosion]

Our contract is based on the [Year] Medicare fee schedule. Code additions and RVU changes since that base year have reduced our effective reimbursement to approximately [Effective Current-Year % of Medicare]% of current-year Medicare, below the [Stated % of Medicare]% stated in our agreement. We estimate that this gap affects annual reimbursement by $[Erosion Amount] across codes introduced or revalued since [Base Medicare Year].

[IF APPLICABLE: LOB Rate Disparity]

We also note a significant rate disparity across your product lines for the same services. For example, our rate for [Example CPT] is $[PPO Rate] on your PPO product but only $[HMO Rate] on your HMO product, while TiC data shows comparable providers receiving $[Market HMO Rate] on HMO for the same code in this market. We request that rates be aligned across all commercial products.

Value to the Payer

[Choose 2 to 3 of the following topics. Focus on the value to the payer as well as the value to patients.]

• Network adequacy and access: [Describe geographic coverage, hours, new patient availability, wait times. If you are one of few in-network providers for your specialty within a certain radius, state that explicitly.]

• Cost efficiency and quality: [Describe outcomes, quality metrics, cost-saving programs, reduced readmissions, ED diversion, and care coordination. Explain the financial or operational benefit to the payer.]

• Operational value: [Describe claims submission accuracy, low denial rates, electronic connectivity, compliance with payer programs.]

• Member retention: [Describe patient satisfaction scores, member loyalty.]

The Request

Based on our market analysis, we are requesting the following adjustments to our commercial fee schedule, effective [Requested Effective Date]:

Option A (Preferred):

Rebase our fee schedule to [Target Percentile, e.g., 75th]th percentile of in-network market rates for our top [Number] CPT codes, with remaining codes adjusted proportionally. This represents an approximate [% Increase Required]% increase to our current fee schedule.

Option B (Alternative):

Convert our reimbursement basis to [Target]% of current-year Medicare (MPFS), updated annually, with a floor escalator of [e.g., 2-3]% per year. Based on our analysis, [Target % of Medicare] would position us at approximately the [Equivalent Percentile]th percentile for our market and specialty.

We are also requesting the following contract protections:

• Annual fee schedule updates tied to current-year MPFS or a guaranteed minimum escalator
• No unilateral fee schedule changes without mutual written amendment and [60/90]-day notice
• Fee schedule load verification within [30/45] days of execution

Next Steps

We have attached:

1. CPT-level market benchmark summary (PayerPrice report)
2. [Any additional attachments, such as a quality report or patient satisfaction data]

We request a written response and a meeting to discuss this proposal by [Date, typically 3 weeks from the date of this letter]. Please contact [Name, Title, Email, Phone] to schedule.

We would welcome the opportunity to reach terms that reflect our market position and support continued access to care for your members.

Sincerely,

[Signature]

[Name and Title]

[Practice Name]

[Phone / Email]

Attachments:

• PayerPrice Market Benchmark Report: Request a demo
• [Additional attachments as applicable]