12 Hidden Threats in Your Payer Contracts

Penny Noyes


January 16, 2014

In This Article

Are You Unknowingly Shortchanging Yourself?

Even when your insurer contract looks above board, it may contain innocent-seeming phrases and clauses that could end up causing you lots of money.

There are many things that payers and networks don't necessarily want you to know about their contracts. It's important to identify and understand the payer contract provisions that could cause the most heartache.

Although there's no guarantee that a network will agree to any of your negotiation requests, at the least you should know what to ask for, what your real deal-breakers are, and what provisions you can manage if you know they exist.

There are some important things to be aware of before you or your administrator go into negotiations with an insurance network. It's important to do your homework.

First Step: Create a State Insurance Law Cheat Sheet

Include typical statutes that you know the insurers must use when creating the terms of your agreement in order to comply with their fully insured business.

Are there state laws addressing timely payment by payers and timely submission/filing of claims by physicians? How do they define medical necessity?

It's also critically important to know about payers' ability to take offsets on your future claims to recover a paid claim for which the payer wants its money back. Your cheat sheet should also include "patient hold harmless" statutes and continuity-of-care requirements upon termination.

After making sure that your rate exhibit reflects what you negotiated, the amendment language is the most important provision to negotiate or manage.

1. One Catch: Implied Acceptance of Notification

For the few states with "material change" laws, there's usually a requirement for the network to give the physician 90 days' written notice of an amendment that will change rates or product inclusion

The catch? Typically the physician gets 30 to 45 days to object. Unfortunately, written objection within this timeframe means that the relationship is terminated, although not responding to such a notice means that there is implied acceptance by the physician.

Often, however, a physician can object and tell the payer that he does not want to exercise the right to terminate; he simply doesn't want the material change (such as proposed rate reduction) to occur or the new product to be added. Whenever possible, negotiate -- don't just accept -- the amendment or material change provisions, especially those related to rates or product inclusion. Try to get the payer to require your prior written consent. This way, you avoid the chance that a notice that doesn't require signature receipt, sent 90 days before the effective date of an amendment, is missed and your silence means acceptance.

Most states have related laws that apply to fully insured plans that are underwritten in the specific state. Keep in mind that self-funded plans are rarely subject to the state laws. Instead, they are regulated by the Department of Labor, which is silent on most of these cheat sheet provisions.

Most states have a law noting that fully insured plans must pay claims within 30 days to 40 days -- some as quickly as 10 days for electronically filed claims. If you know that payers are able to administer and pay claims for their fully insured business in these time frames, try to hold them to that same time period for self-funded plans.

But be aware that the network's and claims administration contract with a large self-funded employer client may have a conflicting timeframe of, say, 60 days. If so, they're unlikely to agree to the shorter fully insured plan's legal timeframe in your agreement with them.


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