Practices may consider limiting the number of plan members from a particular plan when, for example, the plan has significant problems (eg, slow payments, inappropriate bundling, low or inadequate payment rates). Before limiting new plan members for any reason, the contract should be carefully reviewed to ensure that there are no provisions that preclude a practice from taking this step. Note that payers may use different methods of controlling new patient enrollment.

For instance, it was reported to the American Academy of Pediatrics (AAP) that a large national carrier included a provision in its contract that affects a practice's ability to control new patient enrollment to the practice. The provision states, “For such a time as Physician declines to accept new members as patients, Physician shall not accept as patients additional members from any entity or organization which competes with Company.”

Other payers are known to reduce payments for services...

You do not currently have access to this content.