Insurance Contract Checklist

  • Plan name_______________________________________________
  • All attachments, addenda, and documents referenced are attached.
  • All verbal representations made to you are referenced in writing.
  • The contract adequately identifies the entities responsible for payment and provides all contact information needed. You have confirmed the information by actual contact.
  • You have spoken with other doctors of administrators experienced with the plan and asked about ease of communications, prompt payment, and hassle factors.
  • You have requested and obtained a financial statement or other support information verifying the plan’s solvency and financial strength.
  • You have obtained verification that the plan has stop-loss coverage and liability insurance.
  • The contract indicates that your fees will be paid within a certain number of days, and it contains an incentive for the payer to comply, such as interest or penalties.
  • The contract specifies the reimbursement rate in dollars for at least some procedures, or the capitation rate per member per month.
  • The contract allows a reasonable time to submit claims and has a provision for extension of that time because of unforeseen circumstances (for example, employee termination or fraud, severe weather, computer malfunction).
  • The contract has a claims appeal process and you have checked references to find out how well it works.
  • The contract does not require you to hold the plan harmless or indemnify it for any actions other than your own.
  • The contract does not require you to pay the plan’s legal fees in a patient action, dispute, or for any other reason.
  • The contract says you will be compensated for any extra activities required (such as quality assurance or utilization review) and you will receive adequate insurance for those activities.
  • The contract adequately describes quality assurance, utilization reviews, dispute resolution, or other oversight functions.  Those functions appear to be fair, and physicians other than those administratively employed by the plan have input.
  • The contract does not hold you to a standard higher than “a reasonable physician acting under the same or similar situation.”
  • The contract does not require you to obtain an unreasonable amount of professional liability insurance or other coverage.  It also does not require that your policy cover the insurer.
  • The contract does not prohibit you from participating in other plans.
  • The contract does not allow your name to be used in marketing activities without your consent.
  • There is a confidentiality clause prohibiting the plan from making disclosures about you that aren’t indicated in the contract.
  • The contract does not require you to significantly change your billing practices or use of staff, alter your hours, or otherwise make major changes in the way you practice.
  • The contract provides an adequate panel of specialists and ancillary services.
  • The contract allows you to stop taking new patients without penalty.
  • The contract allows you to bill patients your normal fee for non-covered services and medically unnecessary services demanded by patients, and for charges the plan is unable to pay or fails to pay.
  • The contract provides explicit instructions on verification of patients’ eligibility.
  • The contract provides reimbursement when the insurer mistakenly indicates a patient is eligible under its plan.
  • Adequate patients or lives will be available to you from the plan.
  • If capitated, you will receive fee-for-service until an appropriate number of lives are provided.
  • If capitated, you are (ideally) capitated differently for each demographic group you’ll treat.
  • If capitated, the services included are clearly defined.
  • The contract allows you an “easy out” in case of dispute, inadequate patient volume, or any other reason, without penalty and within a reasonable period of time.

Source: Medical Economics/June 4, 2004