Antitrust Policy and Healthcare Providers

The federal laws generally apply to all Health Care Providers

Providers cannot collectively negotiate, hinder or boycott a Health Plan or Insurer from the ability to provide their services in any given area. Providers cannot collectively or individually prevent competition or restrict fair trade.

What this means is that Providers cannot discuss or share reimbursement rates nor collectively set rates or restrictions on any given Health Plan. The antitrust alerts increase when a community IPA has a large majority of providers participating since this would potentially increase the antitrust possibilities.

Example: a group of independent behavioral health professionals cannot get together and discuss contract rates or preferred rates as a group, or exchange information on their billed charges. They also cannot discuss -either agreeing to sign contracts or not signing contracts with a health plan. This includes informal discussions between two or more practices.

Exceptions: if a group of providers such as an IPA agree to a contract that has substantial risk. If a health plan offered a contract that placed the providers at risk; then the providers can come together and negotiate their rates and manage their risk arrangements. Substantial risk is usually defined as 25% of funding.

The alternative that IPAs and PHOs employ is to use a “messenger model”. This method allows the IPA to receive contracts, but the total management of the process is performed by an IPA staff person or independent consultant. The consultant communicates with the health plan and with the proposed contract rates – then sends a ballot of the proposal out to each provider with contract details and rates. However, each provider must act independently and still follow the restrictions as noted above regarding communications with other providers. The provider then can independently accept the rate, reject the rate and proposal, or ask for a counter offer and negotiate. Detailed negotiations can be held with a health plan on an individual basis.

The IPA provides a key role in that it brings the health plan to the table, provides education to the providers regarding fee schedules, and generally establishes a link to the plans for the whole IPA. Health Plans usually prefer IPAs and PHOs since they assist with reaching out to the providers with their contracting needs.

Key: IPA Providers can meet and discuss contracts, Health Plans and management issues such as Plan functions, claims, referrals and authorizations, but not discuss reimbursement terms or individual dispositions concerning a proposed contract.

Click here to download SWBHIPA's Antitrust Policy