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…. • How do I get out of this contract? • Length of contract • Notification time • Notification responsibilities
The devil is in the details • Selling or rental of networks • Medical necessity • Administrative requirements
Reimbursement Schedules • Are they included? • Can they be changed? • Are they the codes you use? • Is the reimbursement adequate?
Appeals Process • What is the appeals process? • Is the appeals process fair? • Is there an independent review permitted as part of the appeal?
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?
All products clauses • Can you pick which products you want to participate with? • Can you “close your panels”?
State Laws • Prompt Payment • All-Products • Retroactive Denials • Uniform Credentialing
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
Evaluate the IMPACT • Revenue • Patient population • Hospital affiliations • Covered services
Turn Contracts into Assets • Take control of your business • Evaluate contracts • Meet with carrier representative
Before you sign… • Ask questions • Look for resources • Network • Compare