Chicago Physician Network Attorneys
Every physician knows that health insurers call most of the shots when it comes to patient care and reimbursements. In an effort to level the playing field, many physicians form joint ventures or integrate their practices. Ideally, such efforts help physicians–and ultimately patients–maintain greater control over their practices. Unfortunately, a poorly conceived physician network may also raise serious antitrust concerns.
How Do Antitrust Laws Affect Physicians?
There are no antitrust laws that specifically target physicians. Rather, the antitrust laws broadly apply to anyone engaged in interstate commerce, which includes physicians who negotiate contracts with third-party payers, including private insurers and Medicare and Medicaid.
Among other things, the Sherman Antitrust Act prohibits “unreasonable” restraints of trade. What exactly is “unreasonable” in the context of the health care market? Most physicians operate as independent competitors. If physicians want to leverage their combined negotiating power with insurers, they can merge their practices. A merger typically does not raise Sherman Act concerns, since the merged firm is considered a single entity that cannot “collude” with itself.
But if competing physicians opt for collaboration that falls short of a merger, this is where antitrust problems may emerge. Physician joint ventures frequently involve pooling of resources to serve a common goal. Federal antitrust regulators–specifically, the Department of Justice (DOJ) and the Federal Trade Commission (FTC)–often scrutinize joint ventures and physician networks to ensure they are benefiting health care consumers and not just the member doctors.
For example, the FTC frequently challenges joint ventures where physicians act as a group to negotiate prices and other competitive terms with insurance companies. Under guidelines established by the FTC and DOJ, such ventures must include a significant amount of “risk sharing” or clinical integration. Otherwise, the agencies may condemn such negotiating tactics as “price fixing,” which is a “per se” unreasonable restraint of trade under the Sherman Act.
Even without risk sharing or clinical integration, competing physicians may still be able to pool some of their administrative costs under the “messenger model” approved by the FTC and DOJ. This basically allows the physicians to designate a common agent or “messenger” to relay information regarding what fees and related terms that each is willing to accept from an insurance company. The messenger then uses this information to let the insurer know what range of offers the physicians might accept. This is not a negotiation, however, and the messenger is not allowed to advise the physicians on what offers to accept or reject.
Call us Today for a Free Consultation
Many physician groups get tripped up in trying to implement the messenger model or otherwise comply with the FTC and DOJ guidelines. This is why it is important to work with an experienced physician network attorney. At the Law Offices of George M. Sanders, P.C., we can advise you on the best approach for your practice and even seek an advisory opinion from the government on whether your proposed venture would comply with the antitrust laws. Call us today at (312) 624-7642 to schedule a free consultation so we can learn more about your needs and how we can best assist you.