The following checklist describes provisions which would be in a physician's best interest in a health care payment plan contract. The checklist is not intended to be a substitute for a complete evaluation and is by no means exhaustive. Therefore, it is strongly advised that you seek legal and business advice prior to executing any health care payment plan contract.
In an ideal health care payment plan arrangement, the following would be true:
- The Contract allows you reasonable time to submit completed bills and allows you to submit bills after the designated time when extra time is required due to circumstances beyond your control.
- The Contract requires the payer to pay you for services rendered pursuant to a mistaken verification if the mistake did not result from your failure to follow the verification procedures provided by the health care payment plan organization (HCPPO).
- The HCPPO has provided you with detailed descriptions of its utilization review, quality assurance, dispute resolution protocols and all other documents relating to your contract and the protocols are fair and provide you with meaningful appeal mechanisms, including access to an Independent Review Organization for medical necessity determinations.
- The Contract provides for payment for emergency care services notwithstanding any pre-authorization requirements and defines emergency care in accordance with the understanding of a prudent layperson.
- If the Contract requires you to provide anything other than medical services (for example, your participation on the HCPPO's peer review committee), it also provides you with adequate legal protection and reasonable compensation for such activities.
- The Contract specifies the amount and type of insurance covering the HCPPO's activities under the Contract and provides that you will be covered as an additional insured.
- The Contract does not require you to obtain more insurance coverage or different types of insurance than your current insurance.
- The fee schedule can be translated into real dollars per hour or dollars per procedure.
- The Contract does not require that you indemnify and hold harmless any other party or agree to be "solely responsible" for any harm to covered patients.
- The Contract provides you the right to reject any new groups of patients or alternate fee arrangements without terminating your right to provide services to existing patients or groups under the Contract.
- The Contract does not contain provisions that require you to significantly alter your practice (for example, with respect to your availability, referral practices, or staffing) or alter the standard of care to which you are held.
- If the Contract provides for or contemplates capitation, risk sharing or withhold arrangements, the descriptions of such arrangements are sufficiently clear and detailed to allow you to fully evaluate the risks that you are accepting and the HCPPO certifies that it has obtained a legal opinion that the arrangements do not violate any law prohibiting incentives to limit medically necessary services.
- The Contract provides that neither party can unilaterally amend the Contract, any related documents, or the fee schedule or terminate the Contract without cause (which is defined in a manner which is fair to both parties).
- The Contract provides that after termination of the Contract and until the HCPPO has made medically appropriate referrals of patients who continue to need your services, including special circumstances patients (as defined by HMO and PPO laws), the payer shall pay your standard fees for services that you render to such patients.
- The Contract allows you to bill patients (unless prohibited by law): (a) when the HCPPO or the payer fails or is unable to pay or, (b) for services not covered by the Contract and (c) when you have advised the patient that the HCPPO or payer has determined that proposed services are not medically necessary.
- The Contract prohibits the HCPPO from disclosing any information provided by you or about you in connection with any credentialling or peer review deliberations, unless such disclosure is otherwise required by law.
- The Contract incorporates any oral or written representations, verbal representations that the HCPPO made to you about the plan and its operation.
- At a minimum the Contract incorporates provisions from Texas law governing the quality, utilization management, and due process standards for HCPPOs.
TMA Contract Evaluation Services
If a health care payment plan contract is raising more questions than it answers, then the Physician's Contract Evaluation Service can help. TMA has arranged a specially priced contract evaluation service for TMA members. For $150, Michael Z. Stern, JD, of the Law Office of Hubert Bell, Jr., will review a new or existing managed care contract for legal pitfalls and provisions that may alter or affect your medical practice. You will receive a written evaluation.
Send your contract along with payment to Michael Z. Stern, JD, Law Office of Hubert Bell, Jr. 1907 N. Lamar Blvd., Ste. 300, Austin, TX 78701. (Reviews of other types of contracts also are available. For a price quote, forward a copy of your contract to Mr. Stern.)
For more information, contact Mr. Stern at (512) 469-9006 or email@example.com, or the TMA Knowledge Center at (800) 880-7955 or firstname.lastname@example.org.
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