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Is the "Managed Care Cartel" Squeezing Your Bottom Line?

money visevia Healthcare Reimbursement Blog

According to an article in the Wall Street Journal on May 27, 2015, antitrust lawsuits in federal court allege that 37 independently owned companies are functioning as a cartel in the healthcare space.  Who are the 37 independently owned companies?  All Blue Cross and Blue Shield companies as well as the Blue Cross Blue Shield Association.  These claims have now been consolidated into two lawsuits, one of which represents health care providers who allege that decreased competition is resulting in lower payments for providers.  It’s obvious that providers and healthcare businesses are feeling the squeeze of decreased payments but a costly and lengthy antitrust lawsuit is far from the best way to fight back.

Providers need to know that managed care contracts usually suffer from two common problems: 1) very important terms are unclear and 2) the cost control provisions are unfair.  In addition to the need for clarity, most managed care agreements lack what many consider to be basic procedural fairness.  For instance, most agreements contain provisions that permit the plan to implement any rules, regulations, policies and procedures the plan desires at any time and often without notice or public dissemination.  The physician does not necessarily know about these things, and such things can undermine the very language of the contract.  To meet these concerns, the following should be helpful: