Fair Contracting and Payment Issues

Since its inception, the PAI has worked to facilitate accurate, fair payment for physicians. Consistent with the terms of the now-expired MDL Settlements, PAI is undertaking a range of activities to (1) shine a light on and combat practices by payers that result in underpayment for physicians and (2) address unfair contracting practices resulting from uneven bargaining power between payers and physicians. PAI’s efforts in these critical areas will include:

• National advocacy to promote legislative and regulatory solutions
•  Support for state medical societies’ efforts to secure state policy initiatives
• Direct advocacy with payers
• Physician education aimed at providing guidance on how to secure accurate payment and fairer interactions with government and private payers
• Legal advocacy through litigation to challenge unfair practices

Recently, the PAI surveyed state medical associations and found that various unfair payer practices continue to plague physicians and consume medical associations’ advocacy attention, including but not limited to:

• Inclusion of “all products” clauses in provider contracts;
• Refusal to recognize valid assignments of benefits;
• Unilateral fee schedule reductions during a contract term;
• Retroactive denial of benefits for patients who the payer inaccurately deemed as covered;
• Unfair payment practices for out-of-network benefits;
• Unfair “rating” and/or “tiering” practices
•  The use of so-called “virtual credit cards” by payers that include transaction fees;
• Remittance practices that fail to comply with HIPAA; and
• Lack of transparency with regard to claims adjudication and payment.

PAI will work to collect and disseminate information regarding these practices that undermine fair and accurate payment and will develop and share tools and resources to help physicians contest these practices.