Many physicians are frustrated by the negative impact that dealing with dominant health insurers can have on their ability to care for their patients and run their practices. This impact is often the result of powerful insurers’ forcing one-sided “take it or leave it” managed care contracts on physicians. These contracts can impose obligations on physicians that hinder their ability to give patients timely, medically necessary care, like when treatment recommendations are subject to onerous preauthorization requirements. These contracts may also fail to obligate the insurer in ways that would protect patient care, e.g., language ensuring that the physician will not be penalized if he or she is a strong patient advocate who is not afraid to challenge insurer coverage decisions.
While you may not be able to change contracts offered to you, state and federal laws may give you rights-rights that you may not know about.
Example 1: You get a letter from an insurer demanding that you refund a payment received over a year ago. The insurer demands the refund because, at the time of service, it mistakenly determined that services you provided were medically necessary. By consulting the Managed Care Contract Legal Database (Database) under the category “Retroactive Denial,” you can find out if your state places any time limits on retroactive denials of prior authorizations.
Example 2: Health Insurer A has just told you that in thirty (30) days it is implementing a new payment edit that will significantly reduce practice revenue. You want to cancel the contract. Searching the Database using the category “Amendments,” you can learn if your state has a law that will let you get out of the contract without being subject to the payment reduction.
Example 3: Health Insurer A offers you a contract that would require you to participate in the health insurer’s “panels,” and one of those panels is a workers’ compensation network. You want to contract with Health Insurer A, but you do not want to be in Health Insurer A’s worker’s compensation business because the associated fee schedule will not cover the cost of the administrative duties. By consulting the category ‘Participation in Plans, Products or Networks” in the Database, you can see if state law will let you sign the contract without having to participate in the workers’ compensation network.
Example 1: You care for several patients with a serious chronic condition. Health Insurer A was recently acquired by Health Insurer X, a massive national insurer. Health Insurer X has just announced that Health Insurer A will now implement new clinical protocols affecting how you will care for those patients. This change is unacceptable, and you want to end your contract with Health Insurer A. But you cannot just drop these patients. Looking under the category “Continuity of Care-Post Contract,” you can find out whether state law will let you continue care for your patients after you terminate the agreement, and, if so, for how long.
Example 2: Health Insurer A has decided to implement some clinical guidelines that you strongly believe are not evidence-based and are being put in place primarily to justify denials of expensive treatment recommendations. You start aggressively appealing every denial of care based on these guidelines. You get a letter from Health Insurer A, stating that the company will be dropping you from its networks in 90 days. You believe that Health Insurer A is retaliating against you for your vigorous patient advocacy and dropped you in retaliation for vigorously opposing its guideline changes. By searching the Database under “Anti-retaliation,” you can see if your state has a law prohibiting the insurer from terminating your contract.
Example 3: Patient A requires an expensive procedure for which you need a prior authorization. You submit a prior authorization request electronically to the patient’s insurer. Two weeks later you get a denial letter. You are dissatisfied with how the entire process went, and so you check with the Database under the category “State Medical Necessity Decisions-Deadlines,” and you find that the insurer has violated state law.
Medical associations can use the Database to support their legislative and regulatory advocacy. For example, suppose a medical association’s members want to change how health insurers use prior authorization in their state. Using the Database, medical association advocates can easily compare what other states have done on that topic. The Database contains model state legislation, developed by the American Medical Association’s (AMA) Advocacy Resource Center, that state medical associations used to enact laws in their states. These model bills cover issues such as physician profiling, prior authorization, surprise billing, payment transparency, physicians assuming risk, network adequacy, and provider directories. Further, very often legislators want to know how many states have enacted requirements that are contained in proposed legislation and the Database can quickly provide that information. The Database also contains AMA policies that fall under the categories that are used to organize state and federal laws.