Related Experiment Videos

Beating the odds: reducing the risk of not being paid by HMOs and IPAs

Jeremy N Miller1

  • 1Miller Health Law Group, APLC, 2029 Century Park East, Third Floor, Los Angeles, CA 90067, USA. info@millerhealthlaw.com

The Journal of Medical Practice Management : MPM
|May 25, 2002
PubMed

Insights

Physicians face payment issues with payers like Health Maintenance Organizations (HMOs). This guide helps practices negotiate better payer contracts and avoid problematic clauses for improved physician reimbursement.

Area of Science:

  • Healthcare Administration
  • Medical Economics
  • Contract Law

Background:

  • Increasing difficulties for physicians in securing timely and adequate payments from various healthcare payers.
  • Prevalence of complex contracts with entities such as Health Maintenance Organizations (HMOs) and Independent Practice Associations (IPAs).

Purpose of the Study:

  • To provide physicians with essential information for investigating healthcare payers.
  • To offer guidelines for negotiating protective clauses within payer contracts.
  • To raise awareness of potential contractual pitfalls for healthcare providers.

Main Methods:

  • Analysis of common issues in physician-payer contract negotiations.
  • Development of a framework for due diligence regarding payer practices.
  • Guidance on identifying and negotiating key contract terms and protective measures.

Main Results:

  • Physicians can improve their contracting position by understanding payer operations and contract terms.
  • Awareness of potential contractual 'traps' is crucial, even when full negotiation is not possible.
  • Informed negotiation can lead to better contracts or a strategic decision to decline unfavorable agreements.

Conclusions:

  • Physicians can enhance their financial stability by proactively managing payer contracts.
  • Strategic contract negotiation and awareness of payer practices are vital for physician practices.
  • Empowering physicians with negotiation knowledge leads to more favorable payment outcomes or avoidance of detrimental contracts.

Related Concept Videos

Standards of Care II01:19

Standards of Care II

Nurses bear specific legal responsibilities under several federal statutes, including:
Healthcare Associated Infections II: Preventive Measures01:22

Healthcare Associated Infections II: Preventive Measures

Essential infection prevention measures are based on the knowledge of the infection chain, the modes of transmission in healthcare settings, and the use of the best practices in all healthcare settings. Compulsory public reporting of healthcare-associated infection rates is needed to allow individuals and the community to make informed choices regarding selecting a healthcare facility.
The best practices for preventing healthcare-associated infections include hand hygiene, patient risk...
Legal Guidelines for Documentation01:06

Legal Guidelines for Documentation

The legal guidelines for nursing documentation are essential for ensuring accurate, professional, and ethical recording of patient care. The guidelines are discussed here:
Introduction To Health Care Delivery System01:18

Introduction To Health Care Delivery System

The healthcare system is constantly changing and complex. Various services are available from different healthcare providers, but gaining access to these services has become challenging for people with limited healthcare insurance. Uninsured people present a challenge to healthcare because they frequently postpone or forego treatment.
The Institute of Medicine (IOM) advocates for a patient-centered, effective, safe, timely, equitable, and effective healthcare system. The National Priorities...
Types of Biopharmaceutical Studies: Controlled and Non-Controlled Approaches01:23

Types of Biopharmaceutical Studies: Controlled and Non-Controlled Approaches

Biopharmaceutical studies constitute a vital field aiming to enhance drug delivery methods and refine therapeutic approaches, drawing upon diverse interdisciplinary knowledge. In research methodologies, the choice between controlled and non-controlled studies significantly influences the study's reliability and accuracy.
Non-controlled studies, commonly employed for initial exploration, lack a control group, rendering them susceptible to biases and external influences. In contrast, controlled...
Heart Failure V: Medical Management01:30

Heart Failure V: Medical Management

Medical Management of Acute Decompensated Heart Failure (ADHF)The primary goals of therapy for patients hospitalized with acute decompensated heart failure (ADHF) include:Relieving symptomsOptimizing volume statusSupporting oxygenation and ventilationMaintaining cardiac output (CO) and end-organ perfusionIdentifying and addressing the cause of ADHFPreventing complicationsProviding patient education on factors precipitating HF exacerbationPlanning for dischargeOngoing monitoring and assessment...