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Analyzing Insurance Contracts

Healthcare professionals often feel intimidated when reviewing insurance contracts, fearing the complexities and potential pitfalls involved. This guide provides a comprehensive analysis of key contract elements, ensuring you understand terms related to length, notifications, reimbursement schedules, and appeals processes. Learn how to evaluate contracts and negotiate non-financial terms effectively. By understanding state laws and administrative requirements, you can make informed decisions that benefit your practice. Take control of your contracts, turning them into assets rather than liabilities.

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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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