Insurance Panel Contracts: What Therapists Should Check Before Signing

Before you sign a provider agreement, get every document it pulls in: the fee schedule, the provider manual and any policies “incorporated by reference.” Then check five things first. How your rates are set, and whether the payer can change them without your signature. Which codes and telehealth services are actually paid. How far back the payer can take money back. How you get out, and what you owe clients afterward. And what else your signature commits you to, such as every product the payer sells or networks that rent your discount.

How a Provider Agreement Is Put Together

A provider agreement is rarely one document. Expect several layers:

• The agreement itself: term, termination, amendments, disputes and each side's obligations.
• A fee schedule or reimbursement exhibit, usually an appendix, listing what you're paid and which codes you can bill.¹
• Documents incorporated by reference: the provider manual, practice guidelines, level-of-care criteria. They're part of the contract though you never sign them page by page.¹
• Plan or product attachments naming which plans and payment methods the agreement covers.²

The American Psychiatric Association's practice handbook advises getting every referenced document before you sign, and warns that a renewal isn't necessarily last year's contract.¹ The AMA's checklist asks whether you get notice when incorporated documents change, and whether you can leave if the changes are unacceptable.²

The Clause-by-Clause Checklist

1. Reimbursement rates

• Look for: how rates are set: a flat fee schedule, a percentage of Medicare or another formula. If it's tied to Medicare, is it the current year's schedule?² APA Services notes that commercial insurers often use Medicare's fee schedule as a benchmark but pay some services above or below it.³
• Look for: whether the payer can adjust rates on its own, how much notice you get, and whether you can dispute the change or leave.²
• Look for: a “most favored nation” clause requiring you to tell the payer if you accept a lower rate elsewhere. The handbook recommends negotiating these out when possible.¹
• Why it matters: the rate in the exhibit is only as solid as the clauses that let it move.

2. Covered codes and telehealth

• Look for: a rate for every code you bill. For psychotherapy that usually means 90791, 90832, 90834 and 90837; the add-ons 90785 (interactive complexity) and 90840 (each additional 30 minutes of crisis psychotherapy); and 90839, 90846, 90847 or 90853 if you use them.⁴ The handbook describes insurers that refused to pay add-on codes.¹
• Look for: telehealth terms. CMS defines place of service 02 as telehealth with the patient somewhere other than home, and 10 as telehealth with the patient at home.⁵ Modifier rules differ: UnitedHealthcare's commercial telehealth policy, for example, says modifiers 95 and GT aren't required but are accepted as informational.⁶ Get this payer's telehealth policy instead of assuming.

3. Timely filing

• Look for: the deadline for claims, corrected claims and appeals, and what date it runs from. The AMA checklist asks whether the window fits your billing cycle and whether you have enough time to appeal a denial.²
• Why it matters: Medicare's limit is generally one calendar year after the date of service,⁷ but a commercial agreement sets its own number. Don't assume they match. For what to do once a claim comes back denied, see how to handle an insurance denial letter.

4. Claims payment and prompt pay

• Look for: how many days the payer has to pay, what counts as a “clean claim,” and any interest or penalty for late payment.²
• Why it matters: most states have prompt pay laws, usually requiring payment or denial within 30, 45 or 60 days, often faster for electronic claims.⁸ Self-funded employer plans are generally outside state laws like these.^{2, 8} If a state-regulated plan pays late, APA Services suggests raising it with the insurer, then your state insurance department,⁸ which you can find through NAIC.⁹

5. Overpayments and recoupment

• Look for: how far back the payer can claim an overpayment, whether you get notice first, whether it can offset against future payments, and whether offsets wait until your appeal ends.²
• Compare: the AMA's physician-favorable sample limits overpayment requests to 365 days from payment and bars offsets without written consent; its payer-favorable sample allows offsets if you don't dispute or repay within 60 days.²
• Why it matters: state limits vary. New York, for example, requires 30 days' written notice and bars starting recovery more than 24 months after the original payment, with exceptions that include suspected fraud and self-insured plans.¹⁰

6. Amendments and manual changes

• Look for: whether amendments need both signatures or take effect by notice. The AMA's payer-favorable sample lets the payer amend on 45 days' notice, effective unless you terminate.²
• Look for: language letting the payer amend the manual or policies at its sole discretion, and any online “click-through” terms.²
• Why it matters: silence becomes agreement. If amendments take effect 30 days after notice unless you object, a rate change sent to an inbox nobody checks is your rate a month later. Some state laws require payers to let you terminate without penalty after a unilateral amendment.²

7. “All products” clauses

• Look for: a requirement to participate in every product the payer offers, now or later, on terms the plan sets. Can you opt out plan by plan?^{1, 2}
• Why it matters: you could be committing to products you've never reviewed. The handbook notes several states limit these provisions.¹

8. Assignment and rental networks

• Look for: language letting the payer assign the agreement, sell or lease its network, or give third parties access to your rates.^{1, 2}
• Why it matters: the AMA describes rental network PPOs that lease provider panels and discounts to other payers, often without the provider's notice or approval.¹¹ The NCOIL model act on rental networks calls for disclosure in the contract, a list of third parties updated at least every 90 days, the discount's source on each remittance, and a right to refuse a discount taken without a contractual basis.¹² State adoption varies.

9. Termination without cause

• Look for: whether the right is mutual and how much notice it takes. The handbook calls sixty to ninety days usual; the AMA checklist uses 30 to 90 days as its example.^{1, 2} Can you leave one plan without ending the whole agreement?²
• Why it matters: the handbook describes clinicians stuck for months because an insurer said it never got their notice. It recommends registered mail, return receipt requested.¹

10. After termination: your clients

• Look for: any duty to keep treating members after the contract ends, for how long, and at what rate. Check non-solicitation terms limiting what you can tell clients afterward.²
• Why it matters: federal law can apply on top of the contract. Under the No Surprises Act, when a contract with a commercial plan ends for reasons other than failing quality standards or fraud, the plan must notify “continuing care patients,” who can elect up to 90 days of transitional care. During that period you accept the plan's payment plus cost sharing as payment in full and follow the plan's policies.¹³ The definition includes people being treated for a serious and complex condition, and these protections don't apply to Medicare or Medicaid enrollees.¹³

11. Hold harmless and indemnification

• Look for: member hold-harmless language, which bars billing members for amounts the payer owes, even if it becomes insolvent, while letting you collect copays and deductibles.¹ State law may require it; North Carolina requires HMO contracts to say an enrollee isn't liable for sums the HMO owes.¹⁴
• Look for: a clause making you indemnify the payer. The handbook suggests asking for mutual language where each side answers for its own acts, and checking with your malpractice carrier.¹
• Why it matters: the first protects clients. The second can create liability your malpractice coverage may not reach.²

12. Non-covered services

• Look for: whether you can bill members your usual fee for services the plan doesn't cover.²
• Why it matters: payer rules are specific. EmblemHealth, for example, allows it only when arrangements are made in advance and the patient signs a document naming the specific service and accepting responsibility for payment; it notes generic waivers are insufficient.¹⁵ Other payers and states set different conditions.

13. Audits and records access

• Look for: what records the payer can request, audit notice and timeframes, and the confidentiality terms.^{1, 2}
• Why it matters: you don't want to promise disclosures that conflict with other legal obligations.¹ HIPAA's psychotherapy notes are a narrow category: notes kept separate from the rest of the record, excluding things like session start and stop times and summaries of diagnosis or treatment plan.¹⁶ Using or disclosing them generally requires the client's authorization, with limited exceptions, and a covered entity can't condition payment on getting one.¹⁷ For legal demands, see what to do with a subpoena.

14. Credentialing and malpractice minimums

• Look for: who handles credentialing and recredentialing, whether you can be paid while an application is pending, and whether the payer must notify you before disciplinary action.²
• Look for: required malpractice limits. Confirm your policy meets them, and calendar recredentialing dates.

15. Confidentiality and non-disparagement

• Look for: gag or no-disparagement clauses that bar negative comments about the plan or telling a client another plan might be better.¹
• Why it matters: they can limit how you advocate for a client, including in appeals. The handbook notes many states prohibit them.¹

16. Dispute resolution and arbitration

• Look for: whether arbitration is binding, which disputes must go to it, how arbitrators are chosen, where it happens and who pays.² Together, those decide what a small billing dispute would cost to pursue.

17. Term and auto-renewal

• Look for: the initial term, automatic (“evergreen”) renewal, and whether renewal gives you a chance to renegotiate.^{1, 2}
• Why it matters: auto-renewal is a problem when terms, especially rates, change without transparency.² Calendar the renewal and notice dates the day you sign.

What's Actually Negotiable

The AMA reports that payers often present contracts as take-it-or-leave-it but that most provisions are negotiable, and that rates and language are often negotiated separately.¹⁸ Its toolkit notes government programs leave little room and leverage depends on context, such as market share and what sets your practice apart.² Both are written for physicians.

For mental health, the psychiatric handbook says network shortages may let you negotiate better fees or terms, and that until a contract is signed its terms are open to negotiation.¹ Ask for specific changes, and get anything agreed into the contract or a formal amendment, not a representative's email.¹

Negotiate for yourself only. APA Services says individual psychologists are always free to decide what rates they'll accept, but that even discussing acceptable fees with competing practitioners can create antitrust risk.¹⁹

Mental Health Parity: Where It Fits

The Mental Health Parity and Addiction Equity Act (MHPAEA) regulates health plans, not your agreement directly. The 2024 final rule required plans' comparative analyses to cover standards related to network composition and out-of-network reimbursement rates, and required plans to collect and evaluate data on access.²⁰ On May 15, 2025, the Departments said they would not enforce the rule's provisions that are new relative to the 2013 rule until a final decision in pending litigation, plus 18 months. The statute's own obligations, as amended in 2021, continue to apply.²¹

As of this writing, the Departments planned to propose replacement rules by December 31, 2026, with a court status update due September 30, 2026.²² On September 8, 2026, the Department of Labor issued Field Assistance Bulletin 2026-03, which names network adequacy, including network admission standards and provider reimbursement methodologies, among its enforcement priorities.²³ Check current status before relying on it.

Parity rules won't hand you a rate. If a plan's network or payment seems to push clients out of network, tell your association's advocacy staff.

Where to Get Help

• Psychologists: APA Services' legal and regulatory staff at praclegal@apa.org,²⁴ and your state psychological association.²⁵
• Social workers: NASW's clinical.practice@socialworkers.org, set up for members' questions about insurance, reimbursement, coding and credentialing.²⁶
• Counselors: ACA's advocacy team at advocacy@counseling.org and its claims denial and insurance resources,²⁷ plus your state counseling association.
• State law: the AMA's free Managed Care Legal Database covers topics such as contract termination, overpayment recovery, prompt payment, rental networks and continuity of care.²⁸ It's written for physicians, so confirm a law covers your license type.
• Regulators: your state insurance department, found through NAIC.⁹ In California, the Department of Managed Health Care reviews provider complaints about the plans it regulates.²⁹
• Professionals: a healthcare attorney for the agreement, and your malpractice carrier for indemnification language.¹

Before You Sign

• Request every document the agreement references, in its current version.
• Confirm a rate for each code and telehealth place of service you bill.
• Write down the timely filing, appeal and recoupment windows.
• Find the amendment clause: can changes take effect by notice, and how do you object?
• Check all-products and assignment language; ask to opt out plan by plan.
• Review indemnification and malpractice minimums with your carrier.
• Calendar renewal, notice and recredentialing dates.
• Put requested changes in writing, and keep a signed copy of everything.
• Have a healthcare attorney review it.

Using AI to Read a 60-Page Agreement

A provider agreement usually has no client PHI, but it is confidential business information. Pasting it into a cloud chatbot sends it to that company; an on-device tool keeps it on your Mac.

Hey Eduardo is a Mac menu-bar app. Highlight a section in any app and press a shortcut, or use Ask About a Document… to open the PDF and go straight to a question. The “What should I watch out for?” preset flags what the text commits you to, what expires, and silent-agreement language such as “amendments take effect unless you object within 30 days.” ⌥⇧D pulls out dates, figures and names: notice periods, filing deadlines, fee schedule amounts. Follow-ups remember the conversation, so you can ask “what happens if I miss it?”

The limits matter. On the local model, each question reads a window of a few thousand words, and Eduardo tells you when a document is longer than that. A 60-page agreement goes section by section: fee schedule, then amendments, then termination. Scanned PDFs have no text layer; ⌥⇧C reads them with Apple's on-device text recognition. It reports only what the text says, doesn't know payer policies and isn't legal advice. Your attorney still reviews the contract.

Local mode is the default: the model runs on your Mac, and nothing captured is sent to Hey Eduardo or any AI company. Cloud mode is opt-in with your own API key and sends captured text to that provider; a Local/Cloud badge is always visible. Recent history is on by default and stays on the Mac (Settings → Reading → Recent turns it off). Requires Apple Silicon and macOS 15 or later. More for therapists and psychologists, and in the guide.

Related: Hey Eduardo for therapists · Hey Eduardo for psychologists · Handling an insurance denial letter · Subpoena for therapy records: what to do · The Hey Eduardo guide