What Is a Contract in Health Insurance

2. What is the requirement for timely submission? Is this reasonable for your practice? While most medical practices file claims daily or weekly to improve cash flow, the timely health plan quote request should be long enough for your practice to identify neglected claims and file them for payment. While some health plans allow up to 12 months for timely submission, a minimum of six months is recommended. Not all insurance contracts are liability contracts. Life insurance policies and most personal accident insurance policies are no-compensable contracts. You can purchase a $1 million life insurance policy, but that doesn`t mean your life value is equal to that amount. Since you can`t calculate your life equity and you can`t set a price, no clearing contract applies. Will the health care plan allow fees to be paid instead of primary care until a predefined membership threshold is reached? This flexibility can be beneficial for the GP when setting up a membership committee. If the size of your panel is small (it.B less than 50 members), the total monthly principal payment can quickly run out and leave your firm with a loss for the month. 4. Does the contract provide for an immediate payment plan? It is reasonable for you to expect your claims to be processed and paid within an acceptable time frame, usually within 30 days. If your state`s department of insurance has passed immediate payment legislation, your contract must state that the health plan or its payers comply with all applicable immediate payment regulations.

If your state`s immediate payment regulations include exclusions such as workers` compensation claims or employer self-funded claims, you should also discuss adding contract language for immediate payment of those claims. Other forms of healthcare that include managed care features include point-of-care plans (SOPs) and physician-hospital organizations (PHOs). A POS plan is a combination of an HMO and liability insurance plan that allows for full coverage within the supplier network and partial coverage outside the supplier network. A patient must choose a primary care physician and may pay a higher monthly fee at the point of sale if the physician is not on the HMO network. Another version of the POS plan creates supplier “steps” that are evaluated based on cost-effectiveness and quality of patient outcomes. A patient can choose a provider for each level and then owes a monthly premium payment set at that level. Since you make a co-payment during your visit to the doctor, your co-payment will be deducted first: $250 to $20 = $230. Then comes your deductible: $230 to $200 = $30. Your co-insurance is next. You are responsible for 20% of $30 or $6.

Your insurance company is responsible for 80% of $30 or $24. Therefore, your overall liability is $20 + $200 + $6 or $226. Therefore, primary care physicians and their staff must be willing to invest a significant amount of time and effort to ensure a successful negotiation and a mutually beneficial contract. While the recommendations in this article are not exhaustive, they are intended to equip you with tools and techniques that you can use in the Medicare negotiation process. (For more information on non-compensation contracts, see “Purchase of life insurance: term or permanent” and “Transfer of ownership of life insurance.”) Before you invest too much time in reviewing contract wording and legal clauses, you need to gather as much information as possible about the health care plan and its strategic plan for your community. This information will help you determine if your practice is operationally, financially and ethically compatible with the health care plan. Review the information on the health care plan`s website to determine its mission, vision and values. Health plan websites often contain other important information, including the financial performance of the health plan and previous data from the Health Care Plan Employer Data and Information Set (heDIS) www.ncqa.org/tabid/59/Default.aspx). Does the health care plan to meet the needs of a group of employers whose employees use your practice extensively for their primary care? A) Insurance: These are the written statements you have made on your application form that represent the proposed risk to the insurance company. For example, on a life insurance application form, information about your age, family history, occupation, etc. are the representations that should be true in all respects. An insurance breach only exists if you provide false information (e.g.

B in important statements. Your age). However, the contract may or may not be invalid, depending on the type of misrepresentation that occurs, assuming you can prove that your facility is an integral part of your community, a unique health care offering, and a choice option for patients. In this case, you have more influence on the contract negotiations. Traditional property and casualty insurance did not offer health insurance because with traditional fee structures, risks were high and returns uncertain. However, after the development of the Blue Cross/Blue Shield plans, traditional insurers took note of community pricing practices and realized that they could enter the market and attract healthier community members at lower rates than the community. By introducing medical screening to identify healthier people and offering lower rates to younger people, these companies have been able to attract low-risk populations into their health plans. As a result, the Blue Cross/Blue Shield schemes had the most at-risk and costly population to insure. Finally, Blue Cross/Blue Shield plans have also begun to use risk separation policies and charge higher premiums to higher risk groups. Finally, when you sit down to enter into appropriate negotiations with your payer`s representatives, you should have enough data to support your claims. Remember that your requirements should be specific and evidence-based. It`s much easier for the payer to reject a general plea for better contractual terms than, for example, a data-driven request for a 5% increase in your reimbursement rate for ultrasound therapy.

Does the health care plan require additional primary care physicians in your geographic area? 5. Does the contract require written notice of policy changes? He should. It is reasonable to expect at least 30 days` written notice of policy changes. In addition, you should apply for a provision requiring the health care plan to meet with you to try to negotiate a mutually acceptable alternative if you object to a proposed policy or procedure. B) Guarantees: The guarantees of insurance contracts are different from those of ordinary commercial contracts. They are imposed by the insurer to ensure that the risk remains the same throughout the policy and does not increase. For example, in auto insurance, if you lend your car to a friend who doesn`t have a license and that friend is involved in an accident, your insurer may consider this a breach of coverage because they weren`t informed of the change. As a result, your application may be denied. 1. Does the health care plan require that only contract providers be able to offer evening and weekend calls? If so, will it work for your practice? Also, review the health care plan`s guidelines for the use of physician assistants (PAs) and Advanced Registered Nurse Practitioners (NAPs).

If your practice uses these providers, make sure you understand the health care plan`s registration and re-enrollment requirements, as well as its policies regarding billing for PA and ARNP services. Many health plans also implement reduced fee plans for physician extenders, so consider the financial impact on your practice as well. Another form of managed care is the Preferred Provider Organization (OPP). An OPP does not replace the traditional fee-for-service provider (such as an HMO with a staffing model) and does not rely on capitation payments to suppliers. Instead, a PPO contracts with individual suppliers and groups to create a supplier network. OPP members can choose any doctor they want for medical care, but when they choose a provider on the PPO network, their co-payments – predetermined and fixed amounts paid per visit, regardless of the treatment received – are significantly reduced, providing them with an incentive to stay on the network. There is no federal law regulating POPs, but many states regulate their operations. There are three basic PPO models: 2. Are the applicable pay lists included as an annex in the contract? You should have access to the health plan`s fee schedule for all services you offer.

Submit at least a list of the services you provide in your practice and ask for the amount of the fee schedule for the services that will be included as an attachment in the contract. If the health care plan is not prepared to disclose eligible amounts, determine why it is withholding the information and proceed with extreme caution. Does the contract involve risks to non-primary health care services? What control do you have over these services? Are services risk-based? Risky contracts often exclude certain categories of services for which the general practitioner cannot easily manage care, such as. B behavioral health services, self-referral services, or emergency services provided outside the service area of the health care plan. .