This article discusses the provisions of agreements between health plans and physicians, dentists and other health professionals who provide health care to plan members. It is intended to guide lawyers who represent health plans, who are invited to design, verify or negotiate a provider agreement with providers who wish to participate in the health plan provider network. The supply agreement is at the heart of the networks of health care providers. Health plans enter into agreements with providers participating in their supplier networks. Sometimes these agreements are made with individual suppliers, while others enter into agreements with groups of providers, such as medical practices, who employ and charge on behalf of each provider. Providers who enter into agreements with health plans are commonly referred to as participating providers, network or network. Unfortunately, the relationship between the health plan and the provider tends to be adversarial and, in this context, health plans and their lawyers regularly refer to supply agreement provisions when disputes arise over a provider`s obligations as a relevant network operator. The offer agreement should address the most controversial issues and be written in clear and concise language for the supplier community. 2.10 Use management and quality improvement requirements: managed car plans will adopt standards and requirements for usage management and quality improvement, which aim to promote the provision of quality and cost-effective healthcare to its members.
When rendering covered services for members, the provider is committed to meeting the requirements of managing the use and improving the quality of the health benefit program, in which each member is registered. These requirements may include, among other things, pre-authorization or pre-certification prior to issuance or obtaining referrals, participation in case management, and coordination of care with other providers. Such usage management and quality improvement requirements may include office audits of medical records, periodic inspections and investigations, case-specific audits and other simultaneous and retrospective audits by SelectHealth and Affiliated Managed Care Plans. Managed Care Plans may also adopt physician-recognized guidelines for clinical practice and require compliance with such guidelines, unless the best of the patient`s interest dictates something else. Managed care plans provide the provider with information about these requirements. The provider is committed to meeting the standards and requirements for managing and improving the quality of managed care plans and to cooperating with managed care plans to improve the performance of managed care plans. It should be noted that states that require health plans to legally establish their supplier agreements define these documents as confidential and are not subject to public scrutiny under government freedom of information laws. This additional level of protection may reduce a health plan`s fears of losing a competitive advantage through the disclosure of proprietary elements of its provider agreements, but health plans are responsible for establishing clean networks of health care providers to provide health services to plan members. Health plans are partly marketed on the basis of the total number of providers on their networks.