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Beating the odds: reducing the risk of not being paid by HMOs and IPAs
1Miller Health Law Group, APLC, 2029 Century Park East, Third Floor, Los Angeles, CA 90067, USA. info@millerhealthlaw.com
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.
Abstract:
Physicians are having increasing problems getting paid by HMOs, independent practice associations and other payers. This article discusses what practices should investigate about payers, and guidelines for negotiating protections in contracts with payers. Even if certain clauses cannot be negotiated, it is important that providers be aware of potential traps in the contract. By using these guidelines, physicians will be able to negotiate better contracts or decide that no contract is better than a bad contract.