What can doctors do to take advantage of the benefits, but avoid the risks caused by rental networks? Carefully check your OPP agreements, preferably with the help of a lawyer, to determine if the OPP intends to “rent” your negotiated rebates to payers. If it is established that the contract authorizes the “lease” of your rebates, make sure that your agreement with the OPP is established: any mention of a health care provider`s “agreement with us” relates to your agreement with the institution that manages the leasing network (your “master`s contract holder”). These participating health care providers are subject to both the main guide and this supplement. This supplement checks if it conflicts with the thought information in the main manual. You will find topics that are not covered in this supplement in the main guide. What is an OPP? As a health facility or individual provider, it is difficult to provide services in Pennsylvania and New Jersey without participating in at least one preferred provider network (OPP). PPOs are a form of managed care in which an intermediary (OPP) forms a network of health care providers and connects health care providers to health service providers such as insurance companies, employers and third-party managers (pay). Providers offer their OPP services at a reduced price because they expect payers to attract patients to them and thereby increase their patient volume. Health care providers that are part of the OPP provider body are “networked” and, because of negotiated rebates, patients who travel to them for services pay less than they pay for similar services provided by health care providers who are not part of the OPP panel or are “networked.” An OPP can be a “win-win” for patients and health care providers, as individual patients who use networked service providers can save money and in-network providers generate higher revenues than the volume of their opP services as “in-network” and therefore less expensive.
In addition to the laws passed by Parliament, several national and federal courts have passed decisions rejecting a payer`s right to make discounted payments to a health care provider when the rebate has been “sold” to the payer without the health care provider`s knowledge. Although none of these cases have been discovered in New Jersey or Pennsylvania, they provide information on how a local court might see this problem. In at least two cases, HCA Health Services of Georgia v. Employers Health Insurance Company, 240 F.3d 982 (11. Cir 2001) and Mitzan v. Medview Services, Inc., 1999 WL 33105613 (Mass. Super, on June 16, 1999), the courts based their analysis on whether the insurer that had accessed the supplier`s rebates was able to provide physicians with the “benefits of their good business.” As early as 2005, some commentators began warning doctors against “silent PPOs”, i.e. against agreements in which an OPP, with which a doctor contracts on an OPP panel, makes available to other payers, without the doctor`s consent, the discounts negotiated by the doctor with this OPP. Often, however, a physician unknowingly agrees to make his negotiated rebates available to other payers in the “rental network” of an OPP, because the physician does not read the fine print in the contract proposed by the OPP. However, practical problems can arise when the provider or patient has not understood that a facility other than the provider requires the patient supplement.
Therefore, the supplier`s agreement with the OPP should require the OPP to require its payers: 1) to inform patients in writing that they are waiting for a payer`s payment bill; and 2) indicate on the patient`s identity card the payer responsible for paying the patient`s supplement, so that the provider is aware that he is not responsible for collecting the patient`s co-payment.
11 April 2021 BBP Admin Uncategorized
Notice: compact(): Undefined variable: limits in /home/pedersen/public_html/recordings/wp-includes/class-wp-comment-query.php on line 860
Notice: compact(): Undefined variable: groupby in /home/pedersen/public_html/recordings/wp-includes/class-wp-comment-query.php on line 860