Important considerations beyond the contract
There are elements outside of the contract that can impact your experience with a payer. During the contracting process, you should familiarize yourself with state and federal laws, administrative manuals and policies, and coding and payment edits. These documents can impact your reimbursement, rights, and responsibilities under the contract.
The contracting process does not end when you sign the agreement. Credentialing and contract loading are typically the next steps after the agreement is signed, and their execution can impact when your contract becomes effective. After the contract is effective, you should monitor contract performance to confirm it meets expectations.
You can help set yourself up for success by being aware of these other considerations.
State and federal laws
Some provisions of your contract may be determined by state or federal law. For example, some or all of the deadlines for claims filing, payment, or payer recoupment may be determined by state law. State laws governing payer contracts vary, so check the laws in your state. To look up state and federal laws that may impact your contract, see the AMA Managed Care Legal Database.
Provider or administrative manuals and policies
Sometimes, contracts include a brief statement that terms outlined in the provider or administrative manual or other payer policies are not specified within the contract but are incorporated into the agreement. As a result, you should familiarize yourself with the provider or administrative manual and applicable payer policies. These manuals and policies specify the payer’s protocols and processes on areas such as prior authorization, billing, claims processing, contact information, and payer resources.
Concerning language
“Subject to Applicable Law, the terms of the Product Addendum(a) and Rate Exhibit(s), and Health Plan’s Policies (e.g. prepayment review of claims), Health Plan agrees to pay Physician for Covered Services rendered to Members, except for applicable Member copayments, coinsurance, and deductibles.”
Where Policies is defined as the following: “Health Plan’s policies and procedures, including, but not limited to, Provider or Administrative Manuals; clinical policy bulletins; payment policies; credentialing/recredentialing, utilization management, quality management, audit, complaint and appeals, and other policies and procedures related to this Agreement. Such policies and procedures may be made available to Physician electronically or through other media and may vary by Product and/or Plan type.”
The language above states the payer will reimburse claims subject to their payment and review policies, which includes anything in their manual, policy bulletins, policies and procedures, etc.
Better language
“Physician shall abide by Payer’s Policies. However, if any provision in these Policies is inconsistent with provisions in this Agreement, the provisions in the Agreement will prevail.”
If the contract refers to the administrative manual or policies, the language above could be inserted to override these documents.
Coding and payment edits
In addition to provider or administrative manuals and policies, payers also apply coding and payment edits as part of their claims adjudication process. It is important to have the payer provide descriptors of all edits, as these will impact payment. Note that many payers have coding edits or reimbursement policies related to downcoding (often called “E/M leveling”) or modifier 25. While your contract may specify reimbursement terms, these other policies can also impact your actual reimbursement, so it is prudent to review such policies and edits before signing a contract.
Academy advocacy on payers
Learn more about the Academy’s advocacy for dermatologists and their patients with private payers.
Links to provider or administrative manuals, policies, and edits for national carriers
Depending on the language in your contract, payers may not be required to inform you of changes to payer policies, especially if the changes are not considered to have a material impact. For that reason, stay up-to-date with any changes that could impact your practice.
To stay informed about payer administrative and policy updates, review payer newsletters and consider subscribing to email updates from payers. Below are links to manuals, policies, and newsletters for some of the biggest private payers.
Aetna
Cigna
Elevance Health (formerly Anthem)
Humana
UnitedHealthcare
Credentialing
Physicians who are becoming a contracted physician with a payer must undergo credentialing, a process by which the payer assesses the qualifications of the physician to ensure they have the proper education, training, and licensure to care for patients. Some payers begin the credentialing process while the contract terms are still being negotiated; others will not start the credentialing process until the physician has returned the signed agreement. Ascertain the anticipated timeline for completing credentialing, because it can be lengthy and vary greatly by payer.
Contract loading
After credentialing is complete and the contract is effective, you should be able to see patients and be paid according to the contract. However, if the contract or a contract amendment recently became effective, check with the payer if you will need to hold claims while the contract is being loaded to ensure proper reimbursement and avoid claims being reprocessed.
Copy of executed agreement
You should always keep a copy of the fully executed agreement and any amendments to the agreement. The payer should provide a copy of the fully executed agreement after they have signed it. If you do not receive one, ask for it from your network management representative.
Monitoring contract performance
After the agreement has been executed, be sure to monitor performance under the contract. Verify that you are getting paid as expected according to the reimbursement terms of the contract. Occasionally, a payer may make an error in loading a contract, and it’s important to catch and correct errors quickly. If you experience other issues with the payer, you should review the terms of your agreement and contact the payer with questions or concerns.
* This information is provided for educational purposes only; individual physicians must make independent judgments about payer contracts. The AAD cannot provide legal advice to its members. For specific questions or individual cases, we encourage members to speak with their legal counsel.
Additional Academy resources
Use the Academy’s appeal letter tool to streamline administration.
Access other resources on private payers, including our private payer appeal letter tool.
Learn more about the Academy’s advocacy for dermatologists and their patients with private payers.
