The excerpts below provides guidance to psychiatrists on contracting with private insurers. Most of the suggestions apply to other mental health professionals as well. However, psychiatrists are in a unique situation–the majority of psychiatrists do not contract with MCOs (psychiatrists are more apt to be fee for service than any other medical specialty) and there is an undersupply of psychiatrists on many private insurers panels. This gives psychiatrists significant leverage in negotiating with MCOs.

Here is the excerpt:
(MCOs) can affect many aspects of your practice, including how much you are paid, which services you are permitted to provide, and how you are expected to provide them. So before you sign any contract, it’s vital that you take the time to read it thoroughly.

Each contract is different, even from the same company.

Also, don’t assume that a renewal contract is the same as the one received “last year.” Often it is not.

Companies may include important contract features in appendixes, addendums, or “attachments” such as provider manuals, which, if you’re not careful, you may be unaware of until it’s too late.

You must be certain to obtain all documents referenced in a contract and to review them all before entering into a contract.

While some contracts may apply to only specific settings, others stipulate that an in-network psychiatrist is in-network at every place he or she provides services.

This requirement has been problematic for some psychiatrists who practice in clinics that accept many forms of insurance but who have private practices where no insurance is accepted.

If the clinic’s contract with an insurer says it covers all its psychiatrists in all practice settings, then psychiatrists who see a
patient in that plan in their private practice are considered in-network providers there as well and will be paid only the in-network fees negotiated under the clinic contract.

Even if the clinic’s contract with the insurer does not stipulate that all places of service are covered, psychiatrists who want to be
considered out of network in other settings must notify the insurer of this fact.

Because many insurance companies are having trouble maintaining an adequate number of psychiatrists in their networks to meet enrollees’ needs, they may make it difficult for psychiatrists to sever their relationship.

APA’s Managed Care Help Line has received calls from members who were unable to get out of their contracts for many months because an insurer maintained it hadn’t received faxes or e-mails that the doctors had sent to convey their change in status.

We recommend that any notifications about a change in status with an insurer be done in writing and be sent by registered mail, return receipt requested.

Other Points to Remember

* Review the contract for any billing and balance-billing provisions
that restrict your ability to bill patients.

* Review credentialing requirements. Personal information, such as
medical history, may be unwarranted if it does not currently affect your
ability to practice….

* Study the confidentiality terms in the contract; federal and state
laws supersede contractual requirements.

* Study utilization-review requirements to learn procedures for prior
authorization, concurrent review, retrospective review, use of formulary
restrictions, access to physician reviewers, and appeal mechanisms.
These topics are frequently covered in the provider manual, which you
should review before the execution of a contract.

* Be aware that contracts give insurers the right to conduct quality-
assurance audits. This is standard and will not create any problems for
you if you do appropriate documentation.

* Pay attention to how the insurer authorizes services in an emergency.
Most companies have a utilization-management process in place that can
authorize emergency services at any time, but the flexibility of the
authorization process varies. Ask detailed questions about the process
before signing a contract.

* Know when each of your current contracts expires and consider
renegotiating if you feel you are not being adequately compensated. You
have nothing to lose.

* Ask questions. Contract negotiation may be possible, especially since
there is such a shortage of psychiatrists on insurance panels. Even if
you cannot negotiate, be sure to ask questions on items about which you
are unclear to ensure you are not entering into a contract that you
can’t live with.

* Make sure that all representations are in writing. You should obtain
any changes or clarifications to the terms of the contract in the body
of the contract itself. Any additional clarifications made by
representatives of the insurance company that do not agree with the
contract should be incorporated in an amendment that conforms to the
contractual requirements.

Summing It Up

We can’t emphasize it too much: Don’t sign any contract until you’re sure you thoroughly understand what you’re agreeing to.

Also, always check with your malpractice carrier to make sure nothing in the contract conflicts with your policy. And always check with your lawyer.

The AMA has created a detailed model managed care contract, with annotations that explain the reasons for including its various components.

In an ideal world, this is the kind of contract you’d be presented with when you join an insurance network.

The model contract is posted at .

A more in-depth discussion of contracting, which includes definitions of the terms you may encounter in a contract, is posted at
.

If you have other questions about contracting, call APA’s Managed Care Help Line at (800) 343-4671.