Obligations of the employer. Many contracts require the employer to provide the practitioner with sufficient space, equipment, supplies or personnel. I do not generally include such provisions, as this requirement is generally accepted; The inclusion of explicit conditions can provide the practitioner with a basis for advocating for a breach of contract if support is not provided in accordance with the practitioner`s requests. However, it may be appropriate to specify the respective obligations of the parties to provide equipment, supplies or support personnel in independent contractor agreements in which the practitioner is expected to provide his or her own equipment, supplies or personnel. If you include such provisions, be sure to reserve the ultimate right to determine which items, services or support personnel are appropriate and confirm ownership of your equipment and your ultimate authority to make all personnel decisions for your employees. It should be noted that states that require health care plans to file their provider agreements define these documents as confidential under the law and are not subject to public scrutiny under state access to information laws. This additional level of protection can reduce (but not eliminate) a health plan`s concerns about losing a competitive advantage by disclosing proprietary elements of its agreements with providers. Obligation of non-competition. In states that allow restrictive agreements against practitioners, add an appropriate non-compete provision in terms of time, purpose, and geographic scope. The provision should apply for the duration of the agreement and for a reasonable period thereafter. You can always do without it if you wish, but if you have it in the deal, it can help avoid a situation where you invest in the practitioner just to get the practitioner to set up a competing practice across the street. Finally, the agreement with the provider should clearly indicate when the provider must notify the health care plan, preferably immediately or without delay, of certain significant changes in the provider`s personal or professional life that, by their nature, raise concerns about the health or safety of plan members.

This allows the health care plan to make a timely decision about the provider`s continued participation in the health care plan provider network. The most significant changes may include the following: The contract must also specify the MCO`s obligations, including his administrative and marketing duties. Will the provider be included in the network lists distributed to subscribers and the lists will be updated regularly? An insurer can be considered monoponic if it has a sufficiently large market share to force doctors to negotiate with the insurer on a payment basis below the market price. If physicians are able to continue operating in the market by simply refusing to participate in the insurer`s product, there may be no monopson power. However, a company that can actually push doctors out of business because of its size and market share by refusing to negotiate with them except on an all-or-nothing basis, would have monopson power. Applicable law and jurisdiction. Confirm that your state law applies to the Agreement and that any dispute must be resolved in court or by arbitration in your specific jurisdiction. The supplier`s contract establishes time limits within which a supplier must submit a claim specific to the insurer. Delays are usually 120 days from the date of delivery, but can last up to a year after the services have been provided.

However, the deadlines must reflect the requirements of the state. You should review applicable laws to confirm that the agreement does not bind suppliers to a schedule that is too short and therefore contrary to state law. Mission. Prohibit the practitioner or contractor from assigning their rights or obligations without your consent. You must retain the right to assign your rights or obligations to your successors, provided that such assignment does not waive the rights of the practitioner. It should be noted that many states prohibit health plans from terminating network providers for actions intended to benefit their patients or from retaliating against network providers. Contracts with suppliers must reflect these limitations. For example, provider agreements under Pennsylvania law may not allow the health plan to provide a provider for, among other things: A good contract with an employed or contract physician or other practitioner can help you avoid regulatory violations and future litigation.

Here is a brief summary of some of the conditions or issues that you should consider in your supplier contracts. Of course, the above plan contains only general suggestions; Other conditions may be relevant to a particular transaction. Once such a contract is signed, the parties must ensure ongoing compliance in order to comply with the relevant regulations. Payment for services not provided or payment outside of contract can potentially result in violations of Stark and AKS. You should regularly review the terms of the contract and performance to ensure continued compliance. The development of healthcare reform, particularly the emergence of third-party payers and managed care, has added new elements to the intrinsic doctor-patient combination, which requires increasingly complex structured agreements that dictate who provides medical services and how, when and what medical services are provided. Today, suppliers should carefully review the terms of each contract before committing to its terms. A good managed care contract, like any other form of business agreement, is clear, consistent, comprehensive and concise.

It will meet both the intent of the parties who determine their respective rights and obligations and the requirements of federal and state law. Representations and Warranties. Consider requiring the practitioner to make certain ongoing representations and warranties, para. B meets the qualifications; has disclosed previous claims against them and other matters relevant to your filing process; is not bound by any regulatory or contractual restrictions that would affect their ability to provide the Services; and will disclose any conflict of interest or financial relationship that may involve Stark or other regulatory requirements. Again, ask the doctor to notify you immediately if they are not complying with the representations and warranties. Notice. Contracts usually contain provisions that set out the terms of termination under the agreement, by .B. notice of violations or termination.

Ensure that regulations are appropriate and achievable. In addition to regular or registered mail, you should consider personal notification, by fax and/or email after proof of delivery. Compliance. If the physician performs or transfers items or services payable by government health programs, you must generally structure the contract to comply with applicable shelters under the Anti-Bribery Act (“AKS”), 42 CFR 1001.952(d) or (i). If the contract is for a physician, it must be structured to comply with the Ethics in Referral Act (“Stark”), 42 CFR 411,355 or 411,357(c), (d) or (l). For more information on these regulatory requirements, please see our Customer Alert, Stark Requirement for Physician Contracts. In addition, the Federal Civil Fines Act prohibits hospitals in general from encouraging physicians to limit medically necessary services payable through government programs. (42 USC 1320a-7a(b)(1)). If the employer is a tax-exempt business, you must also ensure that the remuneration reflects fair market value in order to avoid tax problems under Section 501(c)(3). If your state recognizes the doctrine of corporate medical practice, you may need to structure your agreement to meet any individual requirements applicable to your state. Parties. The contract must specify the parties.

If the contract is concluded with the legal entity of the practitioner, you must identify the person(s) who will provide the services and/or reserve the right to approve these persons and confirm that these persons are required to comply with the relevant terms of the agreement. Physician groups that contract with hospitals or other facilities to provide services “by appointment” must ensure that all referrals within the group meet Stark`s requirements. To fill Stark`s shelters in “group practice,” a group of physicians who wish to enter into a contract with a physician on the basis of an independent contractor must enter into contracts directly with the physician rather than with a group. .