Managed Care Contracting & Provider Payment

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.

What is an Integration Clause and why is it important?

An “Integration clause” in a contract between an insurer and a health care provider has nothing to do with school busing.

Getting to Know the Dispute Resolution Provisions in your Payor Contracts

The dispute resolution provisions in a contract are often skipped over during negotiations, either because the parties negotiating the contract don’t understand them or because the managed care company actively discourages changes to these provisions because they will require the dreaded review by “legal.” 

It is worthwhile to review the dispute resolution provisions in detail and to make sure your staff understands them and follows them. If problems arise in your relationship with the managed care company, a thorough set of dispute resolution provisions can make the difference between a quick resolution or a protracted, expensive process that leaves the provider feeling ill used.

UnitedHealthCare Refusing to Accept Patient Assignment-of-Benefits?

A recent post by Reed Tinsley, a Texas-based CPA, warns about a letter one of his clients received from UnitedHealthcare (“UH”). He quotes the letter as saying "...we are making changes in the way we direct claims payments for services rendered by non-network care providers and facilities. ....UH will pay commercial members directly for services upon receipt of the claim".

The post does not reveal whether these changes are limited to a specific region or benefit plan, including a specific self – insured plan that UHC is administering. It’s likely that the letter from UH doesn’t contain those details, either. This practice is called “refusing assignment”.

Begin at the Beginning - A few words about definitions

Perhaps the most important part of any contract is its definitions section. This is the first place to look to get a glimpse of the payer’s contracting strategy. Perhaps for this reason, some payers have tucked that section into the back of an agreement or made it an attachment. When reviewing definitions, consider these suggestions:

Dealing with Payors when you are Non Participating

Although issues arising with your contracted Payors are frustrating, many payment battles occur when you provide care to a patient who is covered by a payor with whom you don’t have a contract. Here are some of the common issues and some possible solutions for your consideration.

What is a “Silent PPO” and why do you care?

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. The provider signs a contract giving a discount to certain payors and suddenly additional payors, who were not intended recipients of the discount, are discounting their payments.

Using Employers as a Resource

I just had an interesting conversation with the Director of Revenue Management for a specialty care hospital. He told me of a mission he’s on to develop direct relationships with area employers. Unlike many providers who view their relationship with insurers as a primary relationship and only through them have any relationship with employers, he looks for opportunities to meet with local business owners. He feels these are his primary relationship and he would prefer to get to know them without insurers present. He believes this reinforces his view that his hospital and the employers have shared interests- in providing quality care at an affordable price. Insurers are only middlemen and their interests do not necessarily match.