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Upon request by the attending physician, if the Health Plan determines that it does not have a health care provider with appropriate training and experience in its panel or network to meet the particular health care needs of an enrollee, the health maintenance organization shall make a referral to an appropriate provider, pursuant to a treatment plan approved by the Health Plan in consultation with the primary care provider, the non-participating provider and the enrollee or enrollee's designee. Such referral shall be at no additional cost to the enrollee beyond what the enrollee would otherwise pay for services received within the network.
Often, limiting factors because of the practice of a particular specialty will require an override of a generic anti-discriminatory provision in a contract. For example:
Pediatricians:
Pediatricians shall be permitted to limit their practice to those persons under the age of eighteen (18) years of age.
Gynecologists/ Obstetricians
Provider shall be permitted to limit their practice to those persons of female gender.
Often, limiting factors because of the practice of a particular specialty will require an override of a generic anti-discriminatory provision in a contract. For example:
Pediatricians:
Pediatricians shall be permitted to limit their practice to those persons under the age of eighteen (18) years of age.
Gynecologists/ Obstetricians
Provider shall be permitted to limit their practice to those persons of female gender.
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5 practical & achievable ways hospitals can help employers reign in healthcare costs
These days employers are frustrated about healthcare expenditures and what to do about them. Costs continue to escalate, value and quality are measured by the new "yardstick du jour" creating mountains of new data that is often not actionable, employee engagement in money saving behaviors is challenging at best, and there's no way to transfer more of the cost to the employee ledger without serious benefit satisfaction backlash.
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With more than 30 years of experience in health care and hospital operations, marketing, and revenue cycle management, Maria Todd wrote the leading industry books on managed care contract analysis and negotiation written for the medical group and hospital executive audience. Find this book and others authored by Maria on Amazon.com
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