Managed Care

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Managed Care

Your Ethical and Legal Obligations vs The Plan's Utilization Management Policies

Physicians retain the right, as well as ethical and legal obligation, to provide appropriate care whether or not treatment and/or payment is authorized or approved.

Understanding the Silent PPO Arrangement

Take Steps to Prohibit Uncontrolled Access to Your Discounted Rates

Many patients, physicians, hospitals and other providers are victimized by this practice that is outlawed in some states, but only if the provider does not take steps to strategically exclude

Avoid Medical Necessity Denials by Payors

Often, managed care contract boilerplate language requires providers to discount charges to patients who are members of a health plan that deems a particular procedure, service, drug or supply as "medically unnecessary". This allowance in negotiated terms causes hundreds of thousands of unpaid dollars to countless providers. The practice is widespread because the providers did not fully grasp the implications of one word in the draft provision.

Use Caution When Negotiating Provisions for a Health Plan's Inspection of Records

Most providers are familiar with this sort of language and have seen an "access to books, records and papers" provision in each of their contracts. However, this particular language has a few subtleties that can cause lots of problems with reimbursement,

Selective Termination of Payers

Many times healthcare providers are placed in a difficult position in their contracted reimbursement relationships.

Reimbursement for Copies of Medical and Other Records

No one will protect you if you choose to give away your rights. In most states, medical records copy fees are established in law or administrative code. Health Plans often include language in their draft agreements that entitles them to free copies of medical records.