There is a growing trend of plan sponsors and their agents not renewing contracts with pharmacies and physicians. These “non-renewals” are tantamount to network termination, and are nearly always “without cause”, leaving providers unable to provide services to beneficiaries whose health insurance otherwise covers these services.
However, providers have several rights against these terminations, and can take steps to ensure that their contracts are renewed, not subject to termination, or otherwise reverse a “non-renewal.” First, providers have rights under applicable law. Health provider contracts are regulated by the state and federal government and even contract terms that otherwise “allow” an insurer to not renew a contract are modified by law. The Federal Any Willing Provider Law requires plan sponsors and their agents (such as PBMs) to permit the participation of any provider that meets the “reasonable” and “relevant” “standard” terms and conditions of participation under the insurance plan. Similarly, many states have Any Willing Provider laws, which prohibit health insurers from unduly barring participation to such networks. Second, many contracts provide contractual rights that are violated by “non-renewals”, such as notice provisions, requirements to provide a basis for terminations and appeal process for a change in provider contract status. The rights provided by Any Willing Provider laws, coupled with contractual provisions, provide tools for impacted providers to avoid “non-renewals” or terminations.
How Frier Levitt Can Help
Frier Levitt assists providers in fighting the termination and ensuring contracts are renewed. Contact Frier Levitt today to speak to an attorney.
