What should I be aware of when considering contracting with a plan to join its provider network ?

While the law is often silent about the relationship between health plans and the providers who contract with them, much that affects your responsibility to the plan and theirs to you is specified in the contract that plans have with providers.

When considering signing a contract to become a provider in a plan’s network, consider the following: What limitations and exclusions does the plan place on the payment of claims? Does the plan require you to collect patients’ copayments? Does the plan have a system of utilization management, which will involve postpayment review of claims to discover patterns of over-utilization of certain procedures? Does the contract specify limitations and exclusions from coverage for the plan for which you are considering joining the network?

What does the contract say about periodic audits of your office for quality assurance reviews or financial practices? Does the contract refer to other documents such as a dentist handbook, which details what procedures the plan will pay for and what documentation is required? What is the means of terminating the contract for both parties? Is there a continuity of care provision that will require you to continue to see the plan's patients who are in-treatment even after you have terminated from the contract? In addition, how long does that continuity of care period last? These are just a few of the provisions you may want to consider before signing a plan contract.

The American Dental Association provides a service to members of analyzing plan contract provisions and providing comments. This service is available through CDA, which provides previous ADA analyses and or forwards new contracts to ADA for analysis. Contact CDA Practice Support for these analyses.

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