APMA News - March 2011 - (Page 22)

Should You Sign That Contract? By KELLi BACK, EsQ. ment whereby a health plan enters into direct contracts with physicians or physician groups to provide services to members. Now there are more intervening intermediate entities involved, and being a part of a “network” no longer necessarily means being a preferred provider. In relation to a particular network participation agreement, the contract may offer physician participation: 1) in a health plan’s primary network; and/or 2) in a secondary network that is leased by other health plans. Primary networks are provider networks considered “preferred providers” under the health plan. Health plans generally give their members an explicit financial incentive, such as lower copayments or a lower co-insurance percentage, to see physicians in their primary network. Such incentives are specified in the members’ evidence of coverage and may be noted on their membership cards. Health plans also include primary network physicians in their preferred provider directories. Secondary networks are also known as “wrap” or “complementary networks.” A secondary network allows health plans to access discounts when their members receive services from nonpreferred providers (i.e., those not in the plan’s primary network). Physicians participating in secondary networks have a written contract with a network administrator (generally a PPO) obligating them to furnish discounts to health plans (or in some cases, other network administrators) with which the administrator contracts. Secondary network providers are not considered “preferred providers,” and their services are usually subject to the “out-of-network” level of co-insurance or copayment under the health plan. Over the past few years, APMA has received a number of complaints because a physician who thought he or she was out-of-network for a particular plan (e.g., CIGNA) learned that the plan had contracted with a network administrator such as Multiplan and, because the physician had a contract with Multiplan, the physician was now obligated to accept the Multiplan discounted fees for services furnished to CIGNA members. Although an increasing number of states have adopted legislation that requires plans to clearly specify whether or not they rent their networks, network rental can be difficult to discern in contracts. You should carefully review the terms that define to whom you are required to provide services under the contract. Such terms may include, for example, “payer,” “member,” “covered individual,” or “beneficiary.” Make sure that your obligation is narrow and clear. In addition, make sure the assignment clause is as narrow as possible to avoid allowing the network to inappropriately assign its ability to pay at discounted rates to other organizations. Another option to avoid inadvertent participation in a secondary network is to be sure the contract obligates the plan to make you a preferred provider by including you in directories of primary-network providers and provides for advertised differentials in cost sharing in order to provide patient steerage. Editor’s NotE: APMA News will cover issues like provider network contracts, durable medical equipment, and other topics in a new reimbursement column, written by experts in the field of medical reimbursement. Watch the April issue for the first regular column. I ’m often approached by podiatrists and other health-care providers who are being asked to sign new or revised health plan or provider network contracts. They ask for advice about particular clauses they should pay attention to in their decision about whether or not to sign. While it is ideal to have an attorney review health plan or provider network (jointly referred to in this discussion as “plans”) contracts before you sign them, it is not always practical or affordable. Over the past few years, we’ve noticed five clauses that are at the heart of the majority of physician complaints about plan practices and their contracting relationships. Payment Regardless of other conditions of the contract, if the plan does not offer appropriate compensation in light of your practice costs and the number of patients the plan will potentially direct to your practice, it is not worth signing that contract. It is extremely important that you understand the payment provisions under the contract. It is also important that you understand how these provisions interact with the contract’s other provisions (see the scope of participation, reconciliation, and amendment discussion below). If payment is on a fee-schedule basis, ask for the fee schedule before signing the contract. If the plan is unwilling to provide a full fee schedule, the plan should be willing to provide you with—at a minimum—the schedule for the set of codes that you bill most frequently. In addition, ask the plan for any methodology it uses for downcoding and bundling or whether it engages in these activities. If payment is risk-based (for example, dependent on utilization or performance on quality measures), be sure that you understand your upside bonus potential and/or downside risks. If these factors aren’t apparent in the contract language, call the plan’s provider contracting department for an explanation. If the plan has used this compensation mechanism in the past, you may want to ask about the average performance under the plan’s payment mechanism in the past year for your size and type of practice. Scope of Participation (Secondary/Rental Networks) It is important to determine to whom you are agreeing to provide services for the reimbursement set forth under the contract. A physician network is no longer a simple arrange22 APMA News March 2011

Table of Contents for the Digital Edition of APMA News - March 2011

APMA News - March 2011
President’s Message
Contents
APMA News Debuts
Meet the Candidates for Board of Trustees
Should You Sign That Contract?
Are Cash Balance Pension Plans Right for Your Practice?
FDA On Record: Off-Label Promotion
Mentors Cast a Long Shadow
Technofile
Resolutions Submissions
Young Voices
Federal Advocacy Forum
Members Who Know Media
Build a Better Practice with Tools from The National
Annual Scientific Meeting Preliminary Program
Annual Scientific Meeting Registration Form
Annual Scientific Meeting Sponsors
In Short
APMA Out and About
Worthy of Note
APMAPAC Update
Small Business 101
Affiliates Corner
Development Update
2011 Call for Awards Nominations
Classified Advertising
Dates to Remember
Advertising Index

APMA News - March 2011

https://www.nxtbook.com/nxtbooks/apma/news_20240102
https://www.nxtbook.com/nxtbooks/apma/news_20231112
https://www.nxtbook.com/nxtbooks/apma/news_20230910
https://www.nxtbook.com/nxtbooks/apma/news_20230708
https://www.nxtbook.com/nxtbooks/apma/news_20230506
https://www.nxtbook.com/nxtbooks/apma/news_20230304
https://www.nxtbook.com/nxtbooks/apma/news_20230102
https://www.nxtbook.com/nxtbooks/apma/news_20221112
https://www.nxtbook.com/nxtbooks/apma/news_20220910
https://www.nxtbook.com/nxtbooks/apma/news_20220708
https://www.nxtbook.com/nxtbooks/apma/news_20220506
https://www.nxtbook.com/nxtbooks/apma/news_20220304
https://www.nxtbook.com/nxtbooks/apma/news_20220102
https://www.nxtbook.com/nxtbooks/apma/news_20211112
https://www.nxtbook.com/nxtbooks/apma/news_20210910
https://www.nxtbook.com/nxtbooks/apma/news_20210708
https://www.nxtbook.com/nxtbooks/apma/news_20210506
https://www.nxtbook.com/nxtbooks/apma/news_20210304
https://www.nxtbook.com/nxtbooks/apma/news_20210102
https://www.nxtbook.com/nxtbooks/apma/news_20201112
https://www.nxtbook.com/nxtbooks/apma/news_20200910
https://www.nxtbook.com/nxtbooks/apma/news_20200708
https://www.nxtbook.com/nxtbooks/apma/news_20200506
https://www.nxtbook.com/nxtbooks/apma/news_20200304
https://www.nxtbook.com/nxtbooks/apma/news_20200102
https://www.nxtbook.com/nxtbooks/apma/news_20191112
https://www.nxtbook.com/nxtbooks/apma/news_20190910
https://www.nxtbook.com/nxtbooks/apma/news_20190708
https://www.nxtbook.com/nxtbooks/apma/news_20190506
https://www.nxtbook.com/nxtbooks/apma/news_20190304
https://www.nxtbook.com/nxtbooks/apma/news_20190102
https://www.nxtbook.com/nxtbooks/apma/news_20181112
https://www.nxtbook.com/nxtbooks/apma/news_20180910
https://www.nxtbook.com/nxtbooks/apma/news_20180708
https://www.nxtbook.com/nxtbooks/apma/news_20180506
https://www.nxtbook.com/nxtbooks/apma/news_20180304
https://www.nxtbook.com/nxtbooks/apma/news_20180102
https://www.nxtbook.com/nxtbooks/apma/news_20171112
https://www.nxtbook.com/nxtbooks/apma/news_20170910
https://www.nxtbook.com/nxtbooks/apma/news_20170708
https://www.nxtbook.com/nxtbooks/apma/news_20170506
https://www.nxtbook.com/nxtbooks/apma/news_20170304
https://www.nxtbook.com/nxtbooks/apma/news_20170102
https://www.nxtbook.com/nxtbooks/apma/news_20161112
https://www.nxtbook.com/nxtbooks/apma/news_20160910
https://www.nxtbook.com/nxtbooks/apma/news_20160708
https://www.nxtbook.com/nxtbooks/apma/news_20160506
https://www.nxtbook.com/nxtbooks/apma/news_20160304
https://www.nxtbook.com/nxtbooks/apma/news_20160102
https://www.nxtbook.com/nxtbooks/apma/news_20151112
https://www.nxtbook.com/nxtbooks/apma/news_20150910
https://www.nxtbook.com/nxtbooks/apma/news_20150708
https://www.nxtbook.com/nxtbooks/apma/news_201506
https://www.nxtbook.com/nxtbooks/apma/news_201505
https://www.nxtbook.com/nxtbooks/apma/news_201504
https://www.nxtbook.com/nxtbooks/apma/news_201503
https://www.nxtbook.com/nxtbooks/apma/news_201502
https://www.nxtbook.com/nxtbooks/apma/news_201501
https://www.nxtbook.com/nxtbooks/apma/news_20141112
https://www.nxtbook.com/nxtbooks/apma/news_201410
https://www.nxtbook.com/nxtbooks/apma/news_201409
https://www.nxtbook.com/nxtbooks/apma/news_20140708
https://www.nxtbook.com/nxtbooks/apma/news_201406
https://www.nxtbook.com/nxtbooks/apma/news_201405
https://www.nxtbook.com/nxtbooks/apma/news_201404
https://www.nxtbook.com/nxtbooks/apma/news_201403
https://www.nxtbook.com/nxtbooks/apma/news_201402
https://www.nxtbook.com/nxtbooks/apma/news_201401
https://www.nxtbook.com/nxtbooks/apma/news_201311
https://www.nxtbook.com/nxtbooks/apma/news_201310
https://www.nxtbook.com/nxtbooks/apma/news_201309
https://www.nxtbook.com/nxtbooks/apma/news_201308
https://www.nxtbook.com/nxtbooks/apma/news_201306
https://www.nxtbook.com/nxtbooks/apma/news_201305
https://www.nxtbook.com/nxtbooks/apma/news_201304
https://www.nxtbook.com/nxtbooks/apma/news_201303
https://www.nxtbook.com/nxtbooks/apma/news_201302
https://www.nxtbook.com/nxtbooks/apma/news_201301
https://www.nxtbook.com/nxtbooks/apma/news_201211
https://www.nxtbook.com/nxtbooks/apma/news_201210
https://www.nxtbook.com/nxtbooks/apma/news_201209
https://www.nxtbook.com/nxtbooks/apma/news_20120708
https://www.nxtbook.com/nxtbooks/apma/news_201206
https://www.nxtbook.com/nxtbooks/apma/news_201205
https://www.nxtbook.com/nxtbooks/apma/news_201204
https://www.nxtbook.com/nxtbooks/apma/news_201203
https://www.nxtbook.com/nxtbooks/apma/news_201202
https://www.nxtbook.com/nxtbooks/apma/news_201201
https://www.nxtbook.com/nxtbooks/apma/news_201111
https://www.nxtbook.com/nxtbooks/apma/news_201110
https://www.nxtbook.com/nxtbooks/apma/news_201109
https://www.nxtbook.com/nxtbooks/apma/news_201107
https://www.nxtbook.com/nxtbooks/apma/news_201106
https://www.nxtbook.com/nxtbooks/apma/news_201105
https://www.nxtbook.com/nxtbooks/apma/news_201104
https://www.nxtbook.com/nxtbooks/apma/news_201103
https://www.nxtbook.com/nxtbooks/apma/news_201102
https://www.nxtbookmedia.com