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Mastering Payer Negotiations: Insider Strategies from Both Sides of the Table

What if you could sit across the negotiation table from a commercial payer who's also been an FQHC CEO? In this revealing conversation, Jill Steeley interviews Justin Murgel, Senior VP of Provider Networks at Mountain Health Co-Op and former CEO of an FQHC. Justin shares insider knowledge about what payers are really looking for, the biggest mistakes health centers make, and exactly what data moves the needle in contract negotiations. If you've ever felt intimidated by payer negotiations or haven't renegotiated your rates in years, this episode is your roadmap.

Guest: Justin Murgel, Senior Vice President of Provider Networks and Health Innovation, Mountain Health Co-Op

 

About Justin Murgel

Justin brings a unique dual perspective having spent:

  • Nearly 1 year at Mountain Health Co-Op (Senior VP of Provider Networks and Health Innovation)
  • Nearly 2 years as CEO of an FQHC in Helena, Montana
  • 8 years with a private health insurance company as payer contract specialist (Montana and Idaho)
  • 15 years doing behavioral health services as CEO of a mental health center

 

This combination of payer and provider experience makes him uniquely qualified to share what really works in payer negotiations.

 

The Wake-Up Call

Jill's discovery as Provider Network Director: When she joined a commercial payer, not a single FQHC in Montana had renegotiated their rates in probably 10 years. Most didn't even realize they could.

 

The problem: FQHCs feel intimidated by payer negotiations and don't understand their leverage points.

 

The opportunity: You have more power than you think. Payers need you.

 

Key Topics Covered

Understanding Network Adequacy

What it is: CMS dictates what network adequacy looks like through "geo access pinging" (time and distance requirements)

 

What payers must demonstrate:

  • How far members have to travel to essential community providers
  • Access to primary care, family physicians, dental, behavioral health
  • Access to specialists (dermatology, anesthesiology, chiropractic, etc.)
  • Both time AND distance requirements

 

Why it matters for FQHCs: In rural areas, health centers are often the ONLY way payers can meet network adequacy requirements. That's leverage.

 

Annual process: Payers submit network adequacy reports to Department of Insurance, then to CMS. If they don't have adequacy, they must explain how they'll meet it (telehealth, other means).

 

What Payers Are Really Looking For

Top 3 Things Payers Evaluate:

Network adequacy needs (Do they need you to meet CMS requirements?)

Access to care

  • If it takes 6 months to get into larger system but health center can get them in within 2 weeks, that's valuable
  • Captures wellness visits and risk scores (additional CMS funding)

 

Service array and enabling services

  • Behavioral health and substance use treatment
  • Ryan White programs (big focus in CMS audits)
  • Case management and care coordination
  • Clinical pharmacy services
  • Team-based care approach

 

The key question payers ask: How can we build a more robust network with access to primary care and enabling services?

 

FQHCs' Value Proposition vs. Other Providers

What sets health centers apart:

 

âś“ Enabling services already embedded (case management, care coordination)

  • Payers want to pay PMPMs so larger systems can hire someone to manage populations
  • Health centers already have these people embedded by regulation
  • You don't need extra payment to do what you're already doing

 

âś“ Team-based care that actually exists

  • Not just talking about it, you have the team right there doing it
  • Spend more time with patients (vs. nationwide average of 10-12 minutes)
  • Relationship-based service

 

âś“ Integration of services

  • Behavioral health integrated into primary care
  • Substance use treatment
  • Clinical pharmacy embedded in care team
  • All coordinated and connected

 

âś“ Extended hours and accessibility

  • Evenings, weekends, walk-ins
  • Online scheduling capabilities
  • Same-day and next-day appointments

 

âś“ Serve everyone regardless of insurance

  • What you do for one, you do for all
  • No discrimination based on payer type

 

Key Timestamps

  • [00:01:00] Introduction to Justin Murgel and his dual perspective
  • [00:03:00] What surprised Justin most about how payers view FQHCs
  • [00:06:00] Network adequacy explained
  • [00:09:00] Top 3 things payers look for when evaluating FQHCs
  • [00:14:00] Biggest misconceptions FQHCs have
  • [00:18:00] What to do 6-12 months before negotiations
  • [00:22:00] Critical data points to track
  • [00:24:00] Rate structures: What's working in 2025
  • [00:28:00] Medicaid managed care evolution
  • [00:30:00] Clinical pharmacy as leverage point
  • [00:33:00] Network adequacy standards changing
  • [00:36:00] Montana Plus Plan example
  • [00:40:00] Biggest mistakes FQHCs make
  • [00:41:00] How small rural FQHCs can compete
  • [00:45:00] Top 3 priorities for strengthening payer relationships
  • [00:47:00] Attribution challenges and solutions
  • [00:50:00] Advice for intimidated FQHC leaders

 

Resources Mentioned

CEO Connect Bootcamp (Jill Steeley & Steve Weinman):

  • Email templates for requesting renegotiation meetings
  • What data to have in your back pocket
  • What to monitor before negotiations
  • Template for negotiation letter
  • Template for second renegotiation letter (when you need to keep pushing)

 

Connect with Justin:

 

Action Steps

Immediate (This Week):

  1. List all your commercial payers
  2. Identify when you last renegotiated each contract
  3. Pull your payer mix data for last 6-12 months

 

Short-term (This Month):

  1. Identify network directors at each commercial payer
  2. Start building relationships (don't wait for negotiations)
  3. Track your top 5 disease burdens and how you manage them
  4. Calculate your access times (call to appointment, wait times)

 

Before Your Next Negotiation:

  1. Prepare your value proposition with specific data
  2. Document your enabling services and outcomes
  3. Request data sharing with payers
  4. Build your case for rate increases with cost-effectiveness data

 

Ongoing:

  1. Set calendar reminders every 6 months to touch base with payers
  2. Market to county, city, and school district employees
  3. Invite payer network staff and policy people to tour your health center
  4. Don't miss any opportunity to market your services

 

Final Advice for Intimidated Leaders

Remember:

  • They need YOU (network adequacy)
  • You're a medical group offering team-based care
  • You offer behavioral health facility services
  • If you offer pharmacy, you're uniquely positioned
  • Your value proposition is "none compared to larger systems"

 

Don't negotiate alone:

  • Consider getting contract review help (Justin offers this)
  • Use CEO Connect Bootcamp templates and guidance
  • Connect with other FQHC CEOs who've done this successfully

 

You have more power than you think.

 

Connect with Justin at [email protected] or 406-422-9928 for contract review and negotiation support.