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- 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.
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- 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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- 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.
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- 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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- 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.
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- 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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- consult with us to find out whether
the amount offered, whether fee for service or capitated, is
consistent with current fair market value.
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- 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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- 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.
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- 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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