Insights from Ludi

The regulatory environment dictates that hospitals who contract with physicians meet specific conditions in order for the contract to be legal. The conditions are meant to ensure the physician payment is not based on volume or value of business because it can lead to overusing services and increasing overall costs of care. Technically violating your own contracts can lead to multi-million dollar settlements.

Administrative physician agreements have been written for your physicians with help from your legal department or counsel. The clauses are there to be followed for numerous reasons. Perhaps it is to meet your organization’s goals with the way you align with doctors as well as for a variety of compliance reasons. Whatever the reason, it’s important to handle your physician agreements in the way they’re written, even if they’re complex. Failure to do so leaves room for incredible consequences that can affect your organization in a variety of ways.

Finding a ‘foolproof’ process to manage physician agreements can be a greater challenge than anticipated – perhaps so much so that it's often a task that’s put off within the organization. Once you make the decision to better manage physician agreements, there are a number of advantages you can expect to gain throughout the organization. Here’s a 30,000 foot view of changes you will see once you put time and energy into this problem by automating.

Physician administrative agreements are complex largely because of the challenging compliance regulations they must follow. Based on the thousands of agreements we’ve read on behalf of our clients, there is a cycle taking place where the agreements are getting more complicated as the compliance landscape becomes more rigid. This can create a series of problems when it comes to writing and managing these agreements over time. Take a read through the physician contracting errors that we’ve seen throughout agreements that can cause both short and long-term problems.

The regulatory environment is deep with rules governing how healthcare organizations (HCO) behave. One particularly strict law is the Stark Law, governing how HCOs interact with referring physicians. The law prevents HCOs from paying physicians unless a safe harbor is met. Assuming the HCO takes proper care in setting up this agreement, problems can still arise in how the agreement is operationally managed over time. If not followed exactly as written, the organization may fall outside the safe harbor rendering the organization in violation. Because the law is non-intent based, the OIG will not be swayed if the HCO inadvertently violates the law. Meaning, even if there is a technical violation of the law, the full wrath of the law applies.