It’s not uncommon for physician offices to receive solicitations from out of state PPO networks. One such PPO solicitation from Nevada-based Health Management Network (HMN) was recently brought to CMA’s attention.

The HMN agreement is in many ways inconsistent with California law. For example, California law requires PPOs to pay claims within 30 days. The HMN agreement allows 60 days. HMN also requires physicians to file appeals within 60 days. This means that physician offices must be aware of this quick turnaround and able to comply with the requirement.

Before joining any network, particularly one that is leased or rented by other payors, you should carefully review the contract, including the list of payors that would have access to the discounted rates. Physicians should ensure that the proposed compensation, including the payor’s payment policies and the rules it uses to adjudicate claims, will be sufficient to maintain a medical practice. Without doing this analysis, you cannot make an informed decision about signing the contract.

To help physicians negotiate and manage complex third-party payor agreements, CMA has published a contracting toolkit, “Taking Charge: Steps to Evaluating Relationships and Preparing for Negotiations—A Focus on Payor Contracting.” The toolkit is available free to members at the members-only website. Nonmembers can purchase the toolkit for $100 in the CMA bookstore.

CMA has also published a “Silent PPO Action Guide,” which contains an overview of physician discount contracts and discusses the laws that regulate PPO network leasing. The guide is available through CMA ON-CALL (document #1907). ON-CALL documents are available free to members at CMA’s members-only website. Nonmembers can purchase ON-CALL documents for $2 per page in the CMA bookstore.

Contact: CMA’s reimbursement help line, 888/401-5911 or drice@cmanet.org.