Asking for a raise: the letter and the evidence

What data actually moves a payer

A rate-increase request succeeds on the same evidence a payer already tracks about you: your claim volume and case mix by code, any quality or outcomes data you can produce, and how your contracted rate compares to what Medicare pays for the same codes. A letter built on frustration instead of numbers reads as noise a payer can safely ignore.

Pull twelve months of your own remittance data first: total paid per code, denial rate, and how often the same three or four CPT codes carry most of your volume. That's the leverage list — the codes worth negotiating are the ones you bill often, not the rare ones.

Comparison data: build the fee-schedule exhibit before you ask

The single most persuasive page in a rate request is a side-by-side table: your top-volume codes, your current contracted rate for each, and the Medicare locality rate for the same code, pulled from CMS's public fee schedule search tool 1Ref 1Centers for Medicare & Medicaid Services (2026).Physician Fee Schedule Search.The lookup method for pulling the Medicare locality rate for a CPT/HCPCS code to use in a rate-comparison exhibit.. Payers expect this comparison and rarely dispute the Medicare number itself — they dispute whether it's the right benchmark for your specialty.

Build that exhibit before you draft a single sentence of the letter: code, your trailing-year volume, your current allowed amount, and the Medicare locality rate side by side. Medicare's own numbers reset annually through CMS rulemaking, so pull them the same month you send the letter, not from a table you built two years ago 2Ref 2Centers for Medicare & Medicaid Services (2026).Physician Fee Schedule.That the Medicare Physician Fee Schedule is republished annually through rulemaking, so comparison data needs a fresh pull each cycle..

Reading your own contract before you ask

Before requesting anything, read your existing contract closely enough to answer three questions: does it include escalators that raise your rate automatically each year, does it carry lesser-of clauses that cap what you can ever collect regardless of your charge, and when is the renewal or amendment window your contract actually allows. A request sent outside that window often gets a form-letter deferral regardless of how strong your data is.

Reading a payer contract for these clauses before you negotiate tells you whether you're asking for a new number or asking to fix a structural problem — the second conversation is usually more persuasive, because you're not asking for a favor, you're pointing out a term working against both of you.

Request the payer's own fee schedule first

Send the fee-schedule request before the rate-increase letter, not alongside it: most payers will produce the specific allowed amounts for your contracted codes on request, and negotiating from their own published numbers is harder for them to walk back than negotiating from your estimate of what they're paying. Some payers, like Anthem, publish reimbursement policy directly on their provider portal, which is worth checking before you ask for anything 3Ref 3Anthem (2026).Anthem Provider Policies.A named example of a payer publishing its reimbursement policy on its own provider portal, checked before requesting a rate change..

Use the fee schedule they send you, not your remittance history, as the baseline in your comparison table — remittance data can lag a recent contract amendment or a coding change, and a stale baseline undercuts the exhibit you're trying to build.

What goes in the letter

Keep the letter to one page: who you are and how long you've been in network, the specific codes and current rates you're addressing, your comparison table as an attachment, and a single clear ask with a response deadline. Skip the narrative about rising overhead — payers see that in every request and it moves nothing without the data behind it.

Name a number or a range, not just "an increase" — an open-ended ask gives the payer nothing to respond to and often gets answered with silence. If you're also raising a facility vs non-facility rate issue because you changed locations or your billed place of service, separate that into its own line item; it's a different calculation than a straight percentage increase.

The leverage you actually have

Solo and small practices rarely have volume leverage, but they often have something else: a scarce specialty in the payer's network, a service area with few alternatives, or a clean enrollment history the payer has never had to manage a lapse against. Name the specific leverage you have rather than asserting generically that you deserve more.

Confusing credentialing, enrollment, contracting as one blurry process is a common way a rate request stalls — you're negotiating the contracting layer specifically, and being explicit about that keeps the payer's provider-relations team from routing your letter to a credentialing inbox instead. If the payer you're negotiating with sells ACA marketplace plans, a clean claims history is itself worth naming: KFF's analysis of federal marketplace data found in-network denial rates averaging in the high teens with wide insurer variation, while patients appeal well under 1% of denials — a practice that isn't generating that administrative burden is doing the payer a favor worth pricing 4Ref 4Kaiser Family Foundation (2025).Claims Denials and Appeals in ACA Marketplace Plans.Marketplace-plan denial-rate and appeal-underuse data used to frame a clean claims history as leverage when negotiating with a marketplace insurer specifically..

What happens after you send it

Expect weeks, not days: provider-relations teams for even a solo-friendly payer typically batch rate requests into a periodic review cycle rather than answering line by line. Calendar a follow-up date rather than waiting indefinitely, and get any verbal "yes" converted into a written contract amendment before you start billing the new rate — an unsigned promise doesn't change what a claim adjudicates against.

If the answer is no, ask specifically what data would change it next cycle — a payer that says "come back with utilization data" is telling you the ask wasn't wrong, the evidence was thin. Silence is the outcome to plan around: without a response deadline in your original letter, a payer that doesn't want to negotiate simply doesn't reply.

Whatever the outcome, keep the letter, the exhibit, and the payer's written response together in one file for that contract. A denial this cycle is useful evidence next cycle — it shows what you asked for, what you supported it with, and gives you a documented starting point instead of rebuilding the case from scratch in twelve months.