Medical Office Guide to Health Insurance Contracts

Steve Verno

Disclaimer

I am NOT a lawyer. I DO NOT provide legal advice. The information in this presentation is for training purposes only!

Warning!

Health Insurance Contracts can be very complicated and should be reviewed by an expert, preferably a health care lawyer!

Be Advised!

Most health insurance contracts are Pro-Insurance Company

Things To Check

• Silent PPO• Claim Submission• Claim Payment• Overpayments• Appeal• Termination

Silent PPO

Silent PPO

• This Agreement is entered into by and between Insurance Company A, contracting on behalf of itself, Company A and the other entities that are its’ Affiliates (collectively referred to as Company A) and Provider B (Name of Provider).

• Any corporation, partnership or other legal entity (including any Plan) directly or indirectly owned or controlled by, or which owns or controls, or which is under common ownership or control with Company.

• An insurance company could have 5,000 affiliates or entities.

Close the Backdoor!

List anyone and everyone authorized access to YOUR contract within the Contract! If they aren't listed, they aren't allowed access.

Give approving authority, in writing, to any new entity or affiliate that the insurance company wants to add or purchases.

If They Refuse!

Claim Submission

Claim Submission

Physician Group must submit these claim forms to Company A within one hundred eighty (180) days of 1) the date such services were provided when Company A is the primary payor, or 2) the date of Physician Group's receipt of the explanation of benefits ("EOB") when Company A is the secondary payor in order for Physician Group to be entitled to payment for such services provided pursuant to this Agreement.

Which timeframe is to YOUR benefit?

• State Law for claim submission timeframe

• The Patient’s claim submission timeframe

• Federal Regulation 29 CFR 2560-503-1 (ERISA)

If They Refuse!