Eligibility: Contract Language (Payer v Provider) and Sample to Use

Payer contracting negotiations are a critical aspect of managing healthcare costs and ensuring access to care for patients. During contract negotiations, payers and providers work to establish agreements on reimbursement rates, covered services, and other important details. These negotiations can be complex and time-consuming, requiring careful attention to legal and financial considerations. Ultimately, successful negotiations can help to ensure that patients receive high-quality care at a reasonable cost, while providers are fairly compensated for their services. 

What language to negotiate from a provider v a payer’s perspective:

Favorable to physician:

Payor shall be responsible for identifying and verifying eligibility of Members. Payor shall provide each Member with an identification card. It is the Payor’s responsibility to update and maintain eligibility files and systems to ensure that eligibility verification is timely and accurate. Physician may rely on eligibility verifications obtained from a Payor or its designee and Payor shall reimburse Physician in accordance with this Agreement even if a Member is later determined to be ineligible on the date of service.

Favorable to payor:

Physician will verify a Member’s eligibility before providing a Covered Service unless the situation involves the provision of an Emergency Service in which case Physician will confirm eligibility in a manner that is consistent with Law on redeterminations of eligibility. Physician will not be reimbursed for any services furnished to a patient who was not an eligible Member on the date of service