Q&A: Addressing payer diversions in contract language

Wednesday, April 3, 2019

Q: A payer has begun denying authorization for admissions and diverting patients from our hospital to one of our competitors, even when our hospital is closer. I have been advised that there is little we can do unless we add language to our contract with that payer prohibiting diversions. Is this a common practice among payers? What language should we add to the contract to discourage it?

A: If your facility has even one competitor, speak with a contract attorney to introduce language into your contract that would prevent a payer from diverting care. Along with the financial impact on your facility, payer diversions can disrupt patients' continutiy of care, particularly if the physician ordering the care doesn’t have privileges at another hospital. The language should be worded such that diversions would be driven by the facility according to its bed availability and not by the payer based on which of its contracted facilities has the lowest rate.

 

For more informaiton, see The Essential Guide to Healthcare Payer Contracting. This Q&A originally appeared on Revenue Cycle Advisor.

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