The following is contact language you might want to consider putting in to your managed care agreements to combat Silent PPOs:
EXHIBIT A
AMENDEMENTS TO PROVIDER AGREEMENT
(Suggested Language for Silent PPOs)
This document is an Amendment to the Provider Agreement made and entered into _______, by and between these parties, (PPO Name) and Best Provider Health Care.
The terms and conditions of the Provider Agreement remain unchanged except for the following changes to be effective
Add the following Language
(PPO Name) agrees that it will require all Payers to provide and maintain defined, acceptable financial incentives to encourage Participants to use Preferred Provider when healthcare services are required. Acceptable financial incentive is defined as a minimum of a 10% differential in coinsurance between in-network and out-of-network benefits, so that a covered Participant using a Preferred Provider will receive at least 10% greater benefit. Such financial incentives must be clearly outlined in the policy or Summary Plan Description of Covered Participants
(PPO Name) agrees that it will provide Provider with an updated Payer Listing and a list of all Preferred Providers in its network in the State of _____ on a monthly basis.
(PPO Name) agrees that it will require all Payers to provide each Participant with a medical benefit identification card to be presented to Provider at the time of service of within twenty-four (24) hours of emergency service. The identification card must clearly identify the Participant as having coverage under a specific plan or policy providing medical benefits, and must include a telephone number for verification of benefits. The identification card must also clearly include the logo and or name of the PPO. If any identification card presented by Participant contains the name or logo of more than one PPO, the rates negotiated in this Agreement will not apply. No discount will be granted unless a proper identification card is presented by Participant.
(PPO Name) agrees that if any Payer contracted directly with (PPO Name) applies discounted rates to their payments in violation of the requirements of this Agreement, (PPO Name) will be responsible for assisting Provider in obtaining reimbursement for discounts wrongfully applied.
(PPO Name) understands that it is specifically prohibited from leasing, selling or otherwise allowing the use of the negotiated rates in this Agreement to any entity who is not a Payer and a directly contracted client of the PPO. This means no other PPO, broker, network or other entity is allowed to access these contracted rates.
(PPO Name) must provide Provider at least thirty (30) days advance notice prior to the addition of any new Payer client, along with a copy of the plan or policy language outlining the financial incentives to choose Preferred Providers. Provider must then approve or deny participation of that Payer client within thirty (30) days.
(PPO) (Provider)
By:________________________ By: ________________________
Name:______________________ Name:______________________
Title:_______________________
Title:_______________________
Date:_______________________ Date:_______________________
Have questions? I’m here to help.
