Physician Contract. ➢ Since the language re: affiliates and products is vague, there is nothing to prohibit United from selling this network to another health plan, or from offering a non-insurance product (such as a "discount card") wherein your discounts will be offered to people even if there is no underlying insurance product. ➢ This sentence doesn't make sense: "This agreement applies to you and the services you provide in all of your practice arrangements and for all of your tax identification numbers, except if your services are covered under an agreement between us and a medical group that you are part of." ➢ The credentialing plan needs to be in accordance with the North Carolina Uniform Credentialing Law and associated regulations. ➢ Please note the notification requirement. ➢ Within one year--physician must conduct business entirely on an electronic basis. It is unclear whether this refers to claims, or to all transactions (HIPAA transactions include Health Care Claims and Information, Encounter Information, Referral Certification and Authorization, Coordination of Benefits, Health Care Claim Status (Payment and Remittance Advice), Health Plan Enrollment and Disenrollment, Health Plan Eligibility.) This will be defined by United, and may require acquisition of new software in physician's offices. ➢ Claims must supply "all applicable information." This should be defined under HIPAA, but appears open-ended in this agreement. There is no provision for limiting requests for medical records. ➢ The list of reasons under which physician's cannot bill patients include "based on our reimbursement policies and methodologies." Thus United will control whether you can bill a patient. There are no provisions re: what type of notification is required to the patient that the service may not be covered (frequently payors require this in writing). This may be discussed in the policies and procedures (and may include onerous written requirements). ➢ Please note that United has not committed to CMS coding conventions when describing fee schedule updates. HB 1066 in North Carolina requires that physician offices are notified of fee schedule changes. ➢ Refund demands apparently will be made within one year in the absence of fraud, this is an improvement in their current refund policies. ➢ Does the timing requirement at the top of page four mean that there will be a gap in participation for currently participating physicians? ➢ We are opposed to amendment processes that do not require t...
