Recently, I've noticed the escalation of some disturbing trends in managed care. It appears as if some managed care systems are penalizing physicians in an attempt to shore up their own finances. Increasingly, they're making arbitrary decisions that create serious financial problems for once-healthy practices.

They fall into three categories:

• downcoding
(when a payer changes the billing codes on your claim from higher to lower levels without consulting you)
• bundling
(when a payer groups various procedures on your claims, declaring that they're all part of the same procedure, often resulting in decreased payment to you)
• delaying payments
.

Furthermore, managed care companies continue to submit onerous contracts -- and contract amendments -- to ophthalmologists on a take-it-or-leave-it basis. And they make terms, such as services to be provided and compensation to be paid, exceedingly vague.

My advice to you is that of a boxing referee to fighters: You must "protect yourself at all times." The time to do that is before you sign any managed care contract. What follows are two effective ways to do so.

First, you must insist on obtaining copies of the managed care plan's policies and procedures that are "incorporated by reference" into the contract. You should examine these documents as part of the contract review. They typically address a wide array of patient care and other important issues and are usually considered part of the contract.

Second, when you encounter a contract that doesn't outline the crucial issues described above to your satisfaction, you should make sure that the appropriate additions are made.

The American Medical Association suggests the following language, which specifically pertains to protecting your practice against downcoding and the misuse of bundling:

"Payer hereby agrees that claims submitted for services rendered by provider shall be presumed to be coded correctly. Payer may rebut such presumption with evidence that a claim fails to satisfy the standards set forth in the Exhibit. The Exhibit shall include a detailed description of the payer's coding standards and requirements, including, but not limited to, the rules on modifiers, multiple surgeries, evaluation and management coding and bundling policies such as edits, including correct coding initiatives.

"Payer shall not adjust the billing codes submitted by provider on a claim without first requesting additional documentation to satisfy the coding standards described in the Exhibit. Payer must provide adequate notice if it wishes to adjust a code and allow sufficient time for provider to submit additional documentation or explanation.

"Provider has the right to appeal any adverse decision regarding the payment of claims based upon the level of coding with rights and duties as set forth in this Agreement. If Payer reduces payment of a claim in contravention of this section, such party shall be obligated to reimburse provider for the full amount of billed charges for the claim."

Having this type of language in a contract gives you a solid legal foundation to head off any arbitrary attempts at downcoding or bundling.