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Analyzing Insurance Contracts

Analyzing Insurance Contracts. Jama Allers, Practice Consultant MedChi, The Maryland State Medical Society 2008. Read your contracts …. INTIMIDATION FACTOR Fear Overwhelming Beyond my expertise Don ’ t have time They are all the same. First things first … .

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Analyzing Insurance Contracts

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  1. Analyzing Insurance Contracts Jama Allers, Practice Consultant MedChi, The Maryland State Medical Society 2008

  2. Read your contracts… • INTIMIDATION FACTOR • Fear • Overwhelming • Beyond my expertise • Don’t have time • They are all the same

  3. First things first…. • How do I get out of this contract? • Length of contract • Notification time • Notification responsibilities

  4. The devil is in the details • Selling or rental of networks • Medical necessity • Administrative requirements

  5. Reimbursement Schedules • Are they included? • Can they be changed? • Are they the codes you use? • Is the reimbursement adequate?

  6. Appeals Process • What is the appeals process? • Is the appeals process fair? • Is there an independent review permitted as part of the appeal?

  7. Offsets and Overpayment • What is the mechanism in place for overpayments? • Is there a time frame to retract overpayments? • What is the auditing process and timeframe?

  8. All products clauses • Can you pick which products you want to participate with? • Can you “close your panels”?

  9. State Laws • Prompt Payment • All-Products • Retroactive Denials • Uniform Credentialing

  10. Negotiate Non-financial Terms • Require carrier to send fee schedule changes by certified letter • Auto-credentialing for new providers • Pre-authorization terms • Right to close your panels • Termination 30 days

  11. Evaluate the IMPACT • Revenue • Patient population • Hospital affiliations • Covered services

  12. Turn Contracts into Assets • Take control of your business • Evaluate contracts • Meet with carrier representative

  13. Does this contract make good business sense?

  14. Before you sign… • Ask questions • Look for resources • Network • Compare

  15. Need more help?

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