PPO agreement requires self-funded plan to pay certain claims that otherwise would be denied……………………..
How many plan sponsors read their TPA / Managed Care agreements? Here is an excerpt from a redacted BUCA TPA ASO Agreement:
ABC HOSPITAL SYSTEM, the dominant health system in much of (STATE), uses its bargaining power to insist on unique requirements to participate in our network. Our contract with ABC HOSPITAL SYSTEM requires us to pay claims we otherwise would deny such as those not medically necessary or experimental or investigational (but does not require us to pay for services your plan expressly excludes from coverage, such as for cosmetic surgery). (We) will charge your plan for these claims in order to be able to continue providing your plan’s participants with access to ABC HOSITAL SYSTEM’S services on an in-network basis.”
Editor’s Note: This BUCA will allow a plan sponsor to carve out stop loss coverage. However, will the stop loss policy (other than the BUCA’s own policy) mirror this plan payment requirement? Likely not. (Is your E&O policy up to date?)