Beautyman Associates, P.C.
 

 

 

 


 

Define Covered Services

Do Do Not
  • define covered services by reference to a specific list of services to be provided.
  • if practical, list services for which you are not responsible.
  • arrange by contract for back-up services for those services you cannot provide before you commit yourself to provide the services.
  • sign a contract with blanks.
  • sign a contract referencing documents (e.g. manuals, protocols, policies) which are not attached.
  • sign a contract attached to which are protocols with which you cannot abide.




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Confirming Patients's Insurance Eligibility


Do

Do Not
  • insist on the availability from the Payor, 24 hours per day, seven days per week, of a faxed confirmation of eligibility from Payor.
  • insert language guaranteeing payment if you follow the eligibility verification procedure specified in the contract.
  • eliminate any silent PPO clause.
  • sign a contract with vague language in which you promise to "coordinate eligibility of patients with the Payor prior to rendering services."
  • take responsibility for determining whether a patient has additional insurance coverage.
  • take responsibility for coordination of benefits calculation and billing.

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Claims Submission and Payment Procedures


Do

Do Not
  • specify within how many days after services are provided the claim must be submitted.
  • specify that a clean claim is one submitted after one and only one rejection by Payor.
  • specify the circumstances under which a patient can be billed directly.
  • specify the dispute resolution procedure.
  • require payment of any undisputed portion pending resolution.
  • sign a contract containing a vague provision that you will be paid "according to the payment procedure then in effect."
  • sign a contract containing capitated payments which allows the Payor to demand a refund if the Payor learns at a later date that it misreported an earlier month's number of covered lives.




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Amount of Payment


Do

Do Not
  • consult with us to find out whether the amount offered, whether fee for service or capitated, is consistent with current fair market value.
  • sign a contract containing a gag clause.
  • agree to any clause limiting your right to talk about the HMO; clauses that prohibit you from saying anything "might" be detrimental to the HMO can be detrimental to patient care and the public good.

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Length of Contract


Do

Do Not
  • seek a longer term for any contract with favorable financial terms.
  • seek from the Department of Insurance a copy of what the Payor has on file.
  • ask the Payor to provide you with evidence of its financial viability.
  • enter into a long term contract with a new HMO or any Payor which has been reported to be in financial difficulty.
  • sign a contract with a subsidiary in reliance on the economic condition of its parents.
  • accept a termination for no cause if the financial terms are favorable.

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