Managed Care Contracting & Provider Payment

Old Forgotten Contracts … A Cautionary Tale

Once upon a time, several practitioners formed a group.  The group signed a contract to receive referrals from a network.  The group never did receive referrals from the network.  One day the group split up and one particular practitioner continued practicing alone. 

Contract Provisions for Uncertain Times

I was recently asked to describe the current contracting environment between providers and payors.  The word that comes to mind first is “uncertainty”. 

A Few Words about the State Law Addendum

Here is an issue that I have dealt with over and over … on both sides of the table. 

When a Managed Care Organization (“MCO”) uses its form contract in multiple states it often adds different exhibits containing the provisions required by the laws of each state. 

National Conference of Insurance Legislators Adopts Model Legislation Banning Silent PPOs

This past Sunday, the Executive Committee National Conference of Insurance Legislators (“NCOIL”) adopted model legislation intended to stop the activities of “Silent PPOs”.  A “Silent PPO” is an arrangement where one organization buys or uses a discounted rate for services from a health provider or practitioner without the provider’s knowing authorization.[1] 

When do you have a contract with a Managed Care Organization? Part 3: Managing the Effective Date of the Contract

In the last 2 entries, we discussed how to avoid unintended contracts and what Evergreen Clauses are.  Today, we discuss ways to manage the effective date.

When do you have a contract with a Managed Care Organization? Part 2: The Evergreen Clause.

Yesterday we discussed avoiding unintended contracts by beginning to perform services before the contract is finalized without some writing to signal your intentions that these "pre-contract" services are being provided on a non-binding, provisional basis.  Today we discuss "Evergreen Clauses".

When do you have a contract with a Managed Care Organization? Part 1: Avoiding Unintended Contracts.

Although you would think that this question goes without saying, the issue of whether and when a binding contract is formed between a Managed Care Organization and a Provider crops up in several forms during contract negotiations and deserves mentioning.

What is a Network Access Agreement?

I was talking to Marla Durben Hirsch the other day, and she mentioned a warning issued by the California Medical Association to California physicians about a Network Access Agreement.  Apparently this national network is recontracting, so this is an issue that physicians in other states might want to watch. 

Potential Remedy for Silent PPO Activity? Court Allows Damages to Georgia Physicians whose Discount Inappropriately Used

Two Georgia physicians sued Private Health Care Systems, a PPO provider network, claiming that PHCS injured them by inappropriately sharing their names and practice information with a company selling medical discount cards to the uninsured (“Capella”). The physicians claimed that their agreements with PHCS limited their participation to those PHCS plans or products whose members had insurance and PHCS misappropriated their identities for commercial gain when it made their names available to Capella for use by Capella card holders.

Some Considerations when a Payor Offers “Real Time Claim Adjudication”

As I’ve said in previous posts, providers should consider giving their best rates only to those payors and products that yield the highest return – defined as some combination of paying high rates and imposing few administrative hassles. See previous post: Here.

This is certainly true when the payor is offering – or may begin to offer – high deductible health plans.  I’ve been reading lately about payors offering Real Time Claim Adjudication (“RTCA”) as a way to allow accurate collection of a patient's deductible at the time of service.   See earlier post about Aetna. Humana recently touted their RTCA system as saving their “pilot practice” $14,000 per year in billing costs.