APMA News - September 2011 - (Page 36)

Can They Really Do That? By Laura Pickard, DPM FAQs about Private Insurance Contracting, Part II Can a PPO or other provider network administrator “sell” or “rent” my contract? The answer to this question may be “yes” in instances in which your contract includes language that allows for such arrangements. However, unless that language is explicit enough to allow you to understand what you signed up for, such arrangements are unfair. Due to the increasing popularity of health plans with open networks such as PPOs and HMOs with point-of-service (POS) options, insurers and employers have been looking for mechanisms to control costs when a member goes out of network. Rental networks are such a mechanism. Rental networks include secondary networks that allow health plans to access discounts when their members receive services from non-preferred providers (i.e., those not in the plan’s primary network). For example, insurers such as United Healthcare or CIGNA may contract with a number of such networks. When the insurer receives a claim from an out-of-network provider, it searches its database to determine if the provider participates with one or more of the rental networks with which the insurer has contracted. If so, the insurer will then pay the provider at the MultiPlan rate rather than the higher out-of-network rate that would otherwise apply. The contract language allowing for rental or sale of a network is generally not obvious or explicit. For example, a broad definition of “payer” or “affiliate” in the contract may provide the flexibility the network needs to sell or rent the network. In most instances, the physician signed the agreement in order to participate in a primary, or preferred provider, network. However, many of the organizations that offer primary networks also offer secondary networks or, as in the case of MultiPlan’s acquisition of PHCS, a primary PPO network is acquired by an entity that also offers a secondary network. Moreover, in many cases, one network administrator contracts with other network administrators to offer the largest secondary network possible. Any contract that does not obligate the network or its contracted health plans to provide for some sort of member steerage mechanism, such as lower cost sharing for obtaining services from participating providers, or does not limit the members to whom the physician must provide discounted services to those of a specific health plan, may open the physician to participation in a secondary network. Back in the early 1980s, with the development of PPOs, many different provider networks were created, and we all signed up enthusiastically. My 1990 list of provider contracts 36 APMA News September 2011 shows that I was signed up with more than 25 different plans! No one wanted to be left out of these plans. Now, many of these same networks or plans have either merged over the years or have “sold” contracts to other plans offering rental networks. Recognizing the unfairness of such arrangements, a number of states have adopted legislation either prohibiting the arrangements or providing for greater transparency by requiring explicit language to be included in contracts for rental networks. One of the most important things you can do to understand your network participation status and whether your claims are being unfairly discounted is to match patient health plans with any discounts claimed on explanation of benefits (EOB) forms. To do this, you should copy patient membership cards and determine whether the discount being claimed is consistent with the plan under which the patient is covered. If not, you may be participating in a rental network. If you are surprised to find yourself participating in a rental network, you should review your contract. The network or health plan with which you have contracted is obligated to abide by the terms of the contract. If the contract obligates the network to provide for patient steerage mechanisms, such as differential cost sharing, the network may be in breach of the contract by including you in a rental network. Matching patient health plans with EOBs can also assist you in determining whether your claims are being unlawfully discounted through a silent PPO or other repricing arrangement. In these arrangements, there is no contractual authority to apply the relevant discount. To terminate a contract with a rental network, you should follow the instructions in the contract regarding termination, make copies of the relevant documents, and retain them. Because some of these networks are a compilation of other networks, you may have to terminate several contracts in order to stop the unfair discounting. As a proactive measure, when you are considering participation in a new network or plan, take the time to research the organization on the Internet. If the products it offers include “repricing” or “secondary networks,” you should proceed with caution. The next installment addresses the question: Can insurance plans outsource or exclude DPMs from performing certain procedures allowed by our scope of practice? n Dr. Pickard can be reached at ljpickard@apma.org.

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

APMA News - September 2011
President’s Message
Contents
Highlights from the 2011 Annual Scientific Meeting
Residency as a First Step to Parity
Residency Consortium Enhances Podiatric Medical Training
The Value of Building Relationships with Legislators
Reimbursement
Federal Advocacy Forum
IT Consultant
Can They Really Do That?
Members Who Know Media
Technofile
Young Voices
Small Business 101
CPME Update
APMAPAC Chair Report
APMA All Stars
In Short
Worthy of Note
Affiliates Corner
List of Affiliated Organizations
Insurance Advisor
New Members
Death Notices
APMAPAC Update
Bylaws Propositions Due
Development Update
Annual Scientific Meeting Sponsors
Classified Advertising
Dates to Remember
Advertising Index
10 Questions

APMA News - September 2011