Payer Contracting and Reimbursement Require More Attention Than Most Practices Can Spare

Payer contracting and reimbursement commonly get pushed into the background in busy primary care practices. That tendency is understandable, but it should not go unchecked. Contracting issues shape financial performance, staff workload, and the daily experience of clinicians and patients. MGMA’s January 2026 polling found that denials and appeals were the biggest source of revenue-cycle leakage reported by medical group leaders, with many of those problems tied to payer behavior such as medical-necessity denials, prior authorization friction, credentialing issues, downcoding, and incorrect denials that had to be reprocessed. [i]

The real challenge is that payer contracting is rarely just about the fee schedule. A fee schedule can look reasonable, and the contract can still create real problems, like prior authorization denials, coding edits, carve-outs, payment delays, or denial patterns, all of which add administrative burden. In the AMA’s 2024 prior authorization survey, 93% of physicians reported care delays tied to prior authorization, practices reported completing an average of 39 prior authorizations per physician per week, and physicians and staff reported spending about 13 hours each week on that work. [ii] CMS’s prior authorization final rule also reflects the scale of the problem: impacted payers must meet certain new operational requirements beginning in 2026, with API-related requirements phased in for 2027.

At the same time, reimbursement is becoming more strategic. CMS’s 2026 Physician Fee Schedule final rule, which set separate conversion factors for qualifying APM participants and others, underscores how closely payment evolution is becoming tied to value-based care, contract terms, and reimbursement strategy. [iii] There is also more pricing information available than there used to be. CMS says most plans and issuers have been required since July 1, 2022 to post machine-readable files with in-network negotiated rates and out-of-network allowed amounts under the Transparency in Coverage rules. [iv] But MGMA reported in late 2025 that only 18% of medical groups said they use that negotiated-rate data in contract discussions, while many cited lack of time, tools, awareness, or technical skill as barriers. [v]

The financial stakes in this work are real. In a February 2025 national survey, Premier reported that claims adjudication cost providers more than $25.7 billion in 2023, and the administrative cost of fighting denials rose from $43.84 per claim in 2022 to $57.23 per claim in 2023. [vi] Premier also reported that 70% of denials were ultimately overturned and paid, but only after multiple rounds of review. This is a useful reminder that contract management, payment review, and recovery work have measurable financial value for all practices, but the financial return is often far greater when there is executive oversight in place to pursue it consistently.

As noted above, too few medical practices are bringing negotiated-rate data into payer negotiations, which means many practices still enter contract discussions without using one of the clearest sources of leverage available. In Vermont, where Blue Cross Blue Shield of Vermont accounts for a little more than half of the commercial market and the next three carriers account for roughly another quarter, that is not a minor oversight—it is a meaningful financial vulnerability. [vii] And because provider contracting still relies heavily on manual, outdated processes, especially for smaller practices, having someone with managed care contracting experience in your corner can help a practice negotiate more effectively, catch reimbursement problems sooner, and turn contract terms into actual financial results. [viii]

For many practices, the issue is not inattention, it is capacity. Most clinicians and practice leaders are already balancing patient care, staffing, operations, and constant day-to-day problem-solving. It is hard to give payer contracting and reimbursement the level of attention they often require without experienced support. That is where Mansfield Primary Care Support can help. Mansfield gives practices executive-level help with contract review, reimbursement strategy, and the operational pain points tied to payer rules, so leaders can make better decisions, reduce avoidable burden, and put the practice in a stronger position over time.

[I] https://www.mgma.com/mgma-stat/detecting-and-fixing-leaks-across-the-revenue-cycle

[ii] https://www.ama-assn.org/system/files/prior-authorization-survey.pdf

[iii] https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2026-medicare-physician-fee-schedule-final-rule-cms-1832-f

[iv] https://www.cms.gov/priorities/healthplan-price-transparency/overview/use-pricing-information-published-under-transparency-coverage-final-rule

[v] https://www.mgma.com/mgma-stat/using-tic-negotiated-rate-data-to-negotiate-payer-contrac

[vi] https://premierinc.com/newsroom/policy/claims-adjudication-costs-providers-257-billion-18-billion-is-potentially-unnecessary-expense

[vii] https://legislature.vermont.gov/Documents/2026/Workgroups/Senate%20Health%20and%20Welfare/Legislative%20Counsel/W~Nolan%20Langweil~Health%20Insurer%20Solvency%20in%20Vermont%20Issue%20Brief~1-20-2026.pdf

[viii] https://www.caqh.org/hubfs/Industry%20Research/CAQH_Stanford_Contracting%20Issue%20Brief_March%202026.pdf