The following are model contract clauses that you can adapt and use in your plan contracts related to antisteering protection:
- Protect your services, regardless of carve-out. Include a list of the various services that are covered under the contract. State that the plan can contract with a carve-out provider, but that you’ll continue to provide all of the services in the contract as a participating provider at the contracted rates.
- Bar additional administrative burdens unless applied universally. Additional administrative burdens (e.g., referral forms) act to discourage providers from continuing to provide these services because they add time and expense, which cut into revenues. Your clause should state that the plan or carve-out provider can’t impose additional administrative burdens on you unless these burdens are applied to all providers providing the carve-out services, including the carve-out specialty provider.
- Require freedom of choice and no steering. The contract should state that members are free to choose you instead of the carve-out provider and that the plan can’t steer members, either directly or indirectly, to other participating providers, including the carve-out provider.
- Know who is responsible. If the plan delegates duties (e.g., claims processing or utilization management) to the carve-out provider, make sure that you know what has been delegated and that the plan remains ultimately responsible for those duties.
- Keep it confidential. Confirm that the contract requires the plan to keep its terms confidential. This ensures that neither carve-out providers nor your competitors know what your deal is. Note: This week’s tip was excerpted from HCPro’s monthly newsletter, Managed Care Contracting & Reimbursement Advisor. For more information, click here.
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