Review Insurance Marketplace Contracts Before Signing!

The TMA is urging members to carefully review contracts for the new Health Insurance Marketplace – and ask for clarification on critical issues – before deciding whether to participate. Members are also asked to share information on the Marketplace contracts they have received with the TMA for advocacy purposes.

Share contract info with the TMA

The Tennessee Medical Association works to stay abreast of developments with the Affordable Care Act and its impact on physicians and patients. See our available resources on the ACA and the Health Insurance Marketplace or contact the TMA Legal Department at 800-659-1862 for assistance or more information.

CHA Contract Reviewed

Open enrollment for the Marketplace begins October 1 and insurance companies are sending contracts to Tennessee providers, even though plans approved by the state still await CMS approval. Our Legal Department has reviewed the only full contract it has seen so far, from Community Health Alliance (CHA), as well as a Marketplace network “attachment” from BlueCross BlueShield of Tennessee (BCBST). Response deadlines are imminent or already expired but insurers may extend deadlines because of the short turnaround time that was given.

Points to Consider

Below are critical points and suggestions to keep in mind when reviewing and before signing Insurance Marketplace Network contracts, taken from the TMA’s review of the CHA contract:

Be sure to request a copy of the “Provider/Practitioner Administrative Manual/Program Requirements.”

The contract makes several references to policies and procedures found there and it is important to know to what you are agreeing under certain provisions, such as procedures for adverse determination appeals and dispute resolutions, before signing with the plan.

Request an entire fee schedule before agreeing to participate.

The CHA agreement we saw only had a sample fee schedule attached.

Identify a limit on the number of medical records CHA may request to satisfy pre-certification requirements.

The definition of “Utilization Management” or “Utilization Review” does not specify a certain number of records, and some managed care companies request an onerous amount of records for utilization review.

Watch for more information from the TMA.

The section on “Quality Requirements” references mechanisms that you will be required to implement pursuant to section 1311(h) of the Affordable Care Act (ACA) does not take effect until January 1, 2015, and HHS has not yet created regulations addressing these mechanisms. Once promulgated, the TMA Legal Department will review them and educate members on what is required.

Clarify the requirement that physicians be held accountable for healthcare professionals who are “associated” or “affiliated in any way.”

The section titled “Providers Associated With or Employed by the Physician” contains language that is broad enough to incorporate individuals for whom you may not usually be accountable.

Several sections reference the CHA’s “TPA,” or third party administrator…

…which CHA has informed us is HealthScope.

Ask for clarification on a provision that entitles CHA to direct Members to “selected” participating providers.

This language in the “No Membership Guarantee” section alludes to CHA’s potential use of benefit managers, which has caused problems for some of our members recently. Physicians expect reasonable patient steerage but if CHA or its “selected Participating Providers” steer patients away from you to cheaper providers, the reason for accepting the discount rates diminishes. Also, many Marketplace plans nationally are using narrow networks, meaning there may be limited specialist options for referrals.

You may want to negotiate the 180-day requirement for termination notices.

In our opinion, six months is an unusually long period of time for a termination notice but we have heard CHA may be willing to negotiate on this point.

Clarify language in the “Use of Marks or Symbols” section that prohibits you from using CHA’s name, symbol or service mark without prior written consent.

This could be burdensome to physicians who advertise the insurance plans they take on their website or in their waiting room. This could also conflict with state law that allows physicians to report any managed care plans they contract with as part of their provider profile.

BCBST Attachment

The BCBST attachment, called Network E, is for providers who already participate in BCBST’s Network S.

  • The response deadline has already expired but again, there may be extensions granted.
  • Because it is simply an attachment to the existing Network S, there is not much language to review as it incorporates most of the existing provider agreement by reference.
  • As with the CHA agreement, we suggest requesting copies of BCBST’s provider manual and their various reimbursement policies to review before signing, as they are referenced numerous times in the attachment.

Ms. Williams holds a BA in Mass Communications. She has been overseeing the TMA journal and a part of the Communications team since 2004. Before coming to the TMA, she worked in newspaper, radio and television as a reporter and news anchor, and as a freelance writer. *As of Dec, 2013, Ms. Williams is no longer employed by the TMA.

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