Dear Provider Relations Representative,

This letter is to notify you that our contract with your company is nearing term or has expired. (Provider Name) has provided valuable medical services to your insured members during the term of the existing contract. According to our records, we have served approximately XX patients with (Insert Insurance Carrier Name) from (contract onset date) to (current date).

We would like to request a meeting to discuss fee schedule increases for the coming contractual term. As you are likely aware, a number of both commercial and governmental payers are increasing fee schedule allowances to offset medical organization operational costs.

Further, our office has implemented a number of quality improvement measures which we believe will result in improved care to your insured members:

(Customize the following bullet points to more accurately detail your quality improvements or create more appropriate descriptions)

• Clinical performance measurement implementation
• Patient Satisfaction Improvements (use of surveys, new locations, longer hours, organization of support groups)
• Staffing Improvements
• Technology Improvements
• % of fees according to the zip code on consumer affairs that shows I am below the zip code fee acceptable in this zip code. (customize this to match the bottom)

Please indicate your availability for this discussion. We look forward to renewing our contract with your company and providing uninterrupted high quality medical care through our partnership with your health plan.

Sincerely,

(Name)

Optional Request for Additional Disclosure

It appears that our office was not provided with the applicable fee schedule related to this contract or the applicable internal procedures for bundling, coding and outlier application which affect reimbursement. Therefore, we request that this additional reimbursement information be sent to us immediately. Disclosure of the information will allow us to more fully prepare for our upcoming discussion regarding this contract. As of 2018 the average fee at the 70% is_____________ and we are unable to accept the fees you are providing which are in the $40%.  (customize this area)