H-415.987 Improper Discounts by Third Party Payers  

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H-415.987 Improper Discounts by Third Party Payers

H-415.987 Improper Discounts by Third Party Payers

 

Our AMA: (1) advocates that medical services agreements between physicians and preferred provider organizations (PPOs) should adhere to the following principles:(a) Discounts shall be extended only to enrollees of PPOs who have cards identifying them as such.(b) All PPO members eligible for discounts shall be subject to mechanisms that will direct patients to the physician’s practice.(c) The types of entities that can be added to the network shall be identified in advance, and providers shall receive timely notice when payers or employers are added.(d) All members added to the PPO shall be subject to the same mechanisms to direct patients to the physician’s practice.(e) Any discounts applicable to a PPO enrollee shall be disclosed at the time coverage is verified.(f) The sale or other unauthorized use of contract rate information shall be specifically prohibited; (2) encourages physicians to verify carefully that payments received from third party payers only include discounts for the provision of health care services for those patients who are entitled to such discounts; and (3) encourages physicians and physician organizations experiencing the application of improper discounts by third party payers to contact the AMA/State Medical Society Litigation Center. (CMS Rep. 5, I-98; Reaffirmation A-99; Reaffirmation I-99; Reaffirmation A-00; Reaffirmed: CMS Rep. 6, A-10)