Checklist: Contracting With Providers

The following checklist describes things an employer should consider when contracting with providers: 

• Contract between an employer, managed care company and provider clearly states who determines medical necessity. 
• Contract describes appeals procedures. 
• Contract includes quality of care disclaimers. 
• Benefit plan documents, employer handbooks and other communication material clearly conveys plan responsibilities, which services are covered, and appeals procedures. 
• Providers in network are quality providers, qualifications of personnel have been checked, and physicians actively practice in the area in which they review cases. 
• Written materials state that responsibility for determining appropriate care is with employees and physicians. 
• Handbook explains that health plan only determines what will be paid for, not whether employee will receive care. 
• If employer offers several plans, employees have signed statements that they understand the plan they have selected and the implications of the plan.
• Risk-sharing payment arrangements are constructed so they do not discourage providers from practicing good medicine. 
• Employers incorporate hold harmless agreements into contracts with providers. 
• Employer amends general liability policies to cover more than incidental medical malpractice or purchases separate vicarious liability coverage for contingent exposures.

Reprinted with permission. © CCH