We ensure that the contract language is favorable and that provisions regarding amendments don’t allow to move a provider to a standard rate without your written consent.  Below are a few key contract provisions that are important to focus on:

• Timely Filing – Get at least 180 days to file.  In some markets, it is possible to get 365 days.

• Timely Payment –  Make sure that self-insured plans not regulated by your state insurance department have to pay within the same time frames as insured plans.

• Patient Hold Harmless – Most contracts indicate that you can bill the patient for copays, coinsurance and deductibles related to covered services and for billed charges for non-covered services, but many contracts prohibit you from billing a patient for services that plan deems medically unnecessary, when the self-insured employer or payer is insolvent or when your group doesn’t adhere to the payer’s utilization management program.  To the extent allowed by law, we make sure you have the right to have the patient sign a waiver agreeing to be responsible in these circumstances, especially if your group provides services often questioned as cosmetic.

• Binding Arbritation – This may come with a requirement that you may not join a class-action lawsuit.  Ask your attorney about this kind of limitation.

• Look Back Periods – If you have a limit of 180 days to notify the payer of an error, why should it have an infinite amount of time if they discover an error by your practice?  Your state may have a limitation for insured plans, but know that the same time limitation is not imposed by the Department of Labor that oversees self-insured plans.  Negotiate a time limit for requesting refunds by self-insured plans to protect your practice from payers or their agents years later seeking to recover funds.

• Offsets – Some states have offset rules that allow health plans to offset a future patient’s payment because they want to recover a requested refund on another patient.  Know your state law.

• Retro-Eligibility Denials – Lets say you verify a patient’s insurance eligibility and benefits on the date of service.  Most contracts allow the payer to deny payment later on or recover payments retroactively if the employer forgot to notify the claims administrator of an employee’s termination.  Protest this and look to case law if the patients have paid you.  Ask for money back.

• Current Or Prevailing Year Medicare –  Given the outlook on Medicare rates, it is not advisable to agree to any contracts that are tied to “prevailing” or “current” year Medicare.  Tie your rates to a known year.

• Multiyear Escalation Clauses – Most payers don’t want to renegotiate contracts each year and neither do you.  In most cases, it’s easy to develop a multiyear agreement, but don’t forget to ask for an escalator in the second, third and sometimes even fourth year.  Payers will often accept a few percentage points or an amount equivalent to an industry index such as consumer price index.

• All Products Provisions – Make sure that you know what products are included in each contract – such as HMO, PPO, Workers Comp Auto, Medicare and Medicaid programs and eliminate those that don’t make sense for your practice.

  There are certainly more provisions to negotiate with payers and your analysis may be far more intricate than in provided in the above checklist depending on your specialty and location.  These simple items are universal and meant to be used as a guide.

Your staff are already burdened with many other critical tasks that are necessary to operate a health care facility.   Gain peace of mind by allowing professional who specialize in this operation take care of your credentialing and contract negotiations.