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This checklist is designed for attorneys representing health plans who are asked to draft or review an agreement with healthcare providers who will be part of the plan’s provider network. It highlights key legal and business points for you to consider when preparing a provider agreement for use by a plan.
Assemble Your Project Team. Identify someone at the health plan to connect you with appropriate stakeholders who can answer provider network questions as they arise. While there are preferred drafting techniques for provider agreements, some points will require a judgment call based on the plan’s tolerance for risk or its approach to managing provider relationships. You should involve the plan’s decision-makers when drafting those provisions.
Schedule a Meeting. It is often helpful to schedule a kick-off call with the provider network team. Whether you are tasked with drafting a new agreement from scratch or with reviewing and revising an existing one, a discussion with the provider network team can help to clarify the plan’s approach to provider contracting and where you should focus your attention. You may hear about your client’s pain points (i.e., where they have encountered challenges with their network providers in the past) and you can address those issues in the next iteration of the provider agreement.
Obtain Underlying Documents. As you draft or review the provider agreement, you will need to reference some important plan documents:
Draft (or Review) the Provider Agreement. The below topic headings reflect essential provisions of a typical provider agreement. Within each topic are consideration points and discussion prompts for the plan’s provider network team. This is not an exhaustive list. Remember to research applicable federal and state laws, administrative agency rules, and guidance materials on these topics to determine if there are specific requirements that need to be addressed in the context of a health plan provider agreement.
Distribute Provider Agreement and Schedule Follow-Up Meeting. When the agreement is in good form, distribute it to the stakeholders on your project team. Additionally, a follow-up meeting may help to identify and iron out any remaining issues. On the agenda should be a discussion about any pain points raised in the kick-off meeting and how you have addressed them.
Finalize Document. After making any final changes to the agreement, circle back with the plan’s provider network team. There may be logistical issues that require legal input, such as the timing and method of distributing the agreements to providers.
To find this article in Lexis Practice Advisor, follow this research path: RESEARCH PATH: Insurance > Assessing Claims and Coverage > Types of Insurance > Checklists