Third Party Payer Contracting and Reimbursement Disputes
With offices in Atlanta and Augusta, our business and healthcare law firm advises and represents healthcare providers with regard to third party payer contracting legal issues. Certain provisions in third party payer contracts can have a great impact upon a provider’s revenue stream. Our services include:
- Negotiating and reviewing insurer health plans
- Negotiating and reviewing PPO network agreements
- Negotiating and reviewing PHO and IPA agreements
- Negotiating and reviewing third party payer provider contracts
The focus of our law firm is advancing and protecting the financial interests of healthcare businesses in Georgia and South Carolina in the Communities We Serve.
We represent clients in Atlanta and Augusta, Georgia; Aiken, South Carolina, and throughout the Communities We Serve. To schedule a consultation with one of our attorneys, email us at firstname.lastname@example.org or contact us at our office nearest you.The Third Party Payer
Our country’s third-party payer healthcare system forces most healthcare providers to enter into contracts with insurers and “managed care” organizations. “Managed care” and “managed healthcare” are used to describe methods that are intended to lower healthcare costs and enhance the quality of patient care. A managed care delivery system (in theory) lowers costs and improves quality of care by certain techniques, including, financial incentives to physicians and patients to choose less expensive care options, causing plan beneficiaries to share in costs, increasing outpatient surgery and reducing inpatient stays, and closely monitoring high-cost patient situations. There are different types of managed care organizations with varying elements to their business models. Unfortunately, managed care has created significant complications and problems in our healthcare system, which continues to make it difficult for physicians and many other healthcare businesses to deliver healthcare happily and profitably.Georgia and South Carolina Healthcare Lawyers
Some managed care organizations are comprised of doctors; others are a combination of doctors, other providers, and hospitals. Specific examples are Independent Practice Associations (IPA), Preferred Provider Organizations (PPO), and Physician Hospital Organizations (PHO). Generally speaking, physicians enter into contracts (directly or indirectly) with a managed care organization that requires the doctors to agree to discounted fees for their services and, in consideration for their agreement to provide services at lower rates, the managed care entity is responsible for “steering” patients to the doctors. A physician or physician practice group may contract with an IPA or PHO that, in turn, contracts with a PPO, health insurer or large employee in a relationship that will allow for a third-party “payer” (an insurer or employer health plan who pays for healthcare) to pay the provider when a “claim” is submitted for care rendered to a patient. The PPO organizes “networks” of doctors that may be included in a health insurance plan pursuant to contracts referred to as “network agreements.”
Physicians or physician groups may have more than one layer of contracts in order to participate in any particular network. A physician may also be a direct or indirect participant in one or more “networks” for purposes of obtaining additional insured patients. Another part of the “managed care” concept involves healthcare providers (e.g. doctors and hospitals) forming “alliances” that help them improve care, manage utilization and control costs. Participating in physician networks and other managed care arrangements can be very complicated and carries unique risks for physicians.
While managed care contracts can greatly enlarge a healthcare provider’s patient volume, there are financial and business consequences and risks associated with managed care contracts. Before signing any managed care contract, a provider should obtain the assistance of a lawyer with relevant experience.
Our business law firm helps healthcare providers by reviewing, negotiating and drafting contracts. To assist physicians and physician groups in navigating the complexities and nuances of contracting with health plans and managed care entities, we prepared Guidelines for Physician Review of Health Plan Contracts that are published on the Medical Association of Georgia’s website.