General Contract Provisions and Attachments

General Contract Provisions and Attachments As mentioned, Provider Agreement content falls into four broad categories. The first two, Introduction and Provisions Specific to a Managed Care Relationship, are discussed in Part Two. This Part Three discusses the final two categories – General Contract Provisions and Attachments, Addendums, Schedules, Exhibits and Amendments. General Contract Provisions These are viewed as the final part […]

Provisions Specific to a Managed Care Relationship

Provisions Specific to a Managed Care Relationship As mentioned, Provider Agreement content falls into four broad categories. The first two, Introduction and Provisions Specific to a Managed Care Relationship typically contain the following sections, more or less in the order shown: Introduction Identification of Parties and Agreement. This names the parties and says they enter into the contract. WHEREAS […]

Overview of Managed-Care Relationships

Overview of Managed-Care Relationships One of the things that has become a staple of the American healthcare system is managed care. There are different systems, such as Participating Provider Organizations (PPO) and Health Maintenance Organizations (HMO), but they all have certain aspects in common. One of these is managed-care contracts. Relative Lack of State and Federal Government […]

Managed-Care Contract Content Issues

Managed-Care Contract Content Issues As discussed elsewhere on this site, one of the things that has become a staple of the American healthcare system is managed care contracts between healthcare Providers and Payors, Insurers or Networks. Although major insurers and networks such as Aetna, Blue Cross, CIGNA and United Healthcare have detailed boilerplate contract templates, Providers often run […]

Motor Vehicle Accidents and Health Insurance

Motor Vehicle Accidents and Health Insurance One common cause of patients seeking hospital treatment is motor vehicle accidents, generally referred to as MVA’s, although nowadays the reporting forms used by law enforcement personnel to report traffic accidents generally are referred to as a Crash Report. Not providing health insurance information For a variety of reasons, patients who […]

ERISA Plan Benefit Disputes

ERISA Plan Benefit Disputes If an ERISA healthcare Plan is fully funded, the process for a Provider to appeal a denied claim is generally very similar to appeal with an individual health insurance policy. Accordingly, the following addresses self-funded Plans. Coverage and benefits disputes Sometimes, after the patient has been treated and the Plan has […]

ERISA Plan Funding

ERISA Plan Funding Regarding healthcare coverage, an ERISA Plan can be either “self-funded” or “fully funded”. The Plan documents determine which funding model applies. The Plan Beneficiaries don’t get to choose between self-funded and fully funded. Self-funded ERISA healthcare Benefit Plans “Self-funded” means exactly what it says – benefits are paid out of Plan funds. […]

ERISA Plan Benefits and Restrictions

ERISA Plan Benefits and Restrictions ERISA does not require an Employer, Plan Sponsor or a Plan to provide either any particular type of benefits (e.g., retirement) or any particular level of benefits – one Plan might provide for retirement benefits and healthcare benefits for unmarried children under age 25 living in the Employee’s household; another might only provide healthcare […]

ERISA Health Plan Fundamentals

ERISA Health Plan Fundamentals In the employee-benefits context, an Employer sets up a “employee benefit plan”, (“Plan”) usually governed by a federal statute known as the Employee Retirement Income Security Act of 1974, commonly referred to as ERISA (pronounced “eh-rih-suh”), found in Title 29 of the United States Code at 29 U.S.C. §1001 et seq. A Plan […]

Multiple Payors and Coordination of Benefits (COB)

Multiple Payors and Coordination of Benefits (COB) One aspect of the healthcare system that frequently leads to confusion and difficulty obtaining proper payment for health care services is coordination of benefits (COB). What happens when there is more than one entity potentially liable to pay for health care treatment? Potentially liable entities For coordination of benefits purposes, […]

Common Causes of Improper Healthcare Claim Denials

Common Causes of Improper Healthcare Claim Denials One of the most common aspects of patients interacting with the healthcare system is health insurance. Generally, a health insurance policy provides that the insurer will pay for certain healthcare services covered by the insurance policy. A somewhat similar arrangement often confused with health insurance is an employer-sponsored self-funded ERISA plan, […]