Contract disclosure: How PPOs can earn praise, not profanity

Like any other kind of health plan, preferred provider organizations must be open and honest in their contracting with physicians if they want to maintain good reputations.

Editorial. Aug. 4, 2003.

When it comes to public perception of what's wrong with health care coverage, PPOs have led a charmed life. HMOs were the only ones mentioned by name when Helen Hunt's character tore into managed care in her famously profane speech in the movie "As Good As It Gets." And an HMO executive was a target when Denzel Washington held a hospital staff hostage in "John Q."

So far as we know, neither movie has a sequel in the works giving characters a shot at complaining about preferred provider organizations. But in real life, many physicians are ready to give their own profanity-spiced speeches about PPOs. Doctors increasingly complain that PPOs are engaging in the same kind of contract abuses -- failing to state payment terms, changing contracts without physicians' knowledge, etc. -- attributed to HMOs.

With PPOs in mind, the AMA House of Delegates in June passed a resolution expanding upon previous policy -- first enacted in 1995 -- to get insurers to make full disclosure of contract terms to physicians. The latest resolution calls for:

• Payers to make a copy of the executed contract available to physicians within three business days of the request.
• All health plan explanations of benefits to contain documentation regarding the precise contract used for determining the reimbursement rate.
• All contracts to be made available once a year for physician review at no cost.
• No contract to be changed without a physician's prior written authorization and when a contract is terminated pursuant to the terms of the contract, the contract may not be used by any other payer.