Legal Framework Requirements
- ERISA compliance: Direct contracts must comply with ERISA plan document requirements
- Provider credentialing: Contracted providers must be credentialed and licensed
- Liability allocation: Contract must clearly allocate liability for medical malpractice and claims disputes
- HIPAA compliance: Business associate agreement required for providers who receive PHI
- No Surprises Act: Direct contracts must comply with NSA balance billing protections
- State law compliance: Direct contracts must comply with applicable state insurance laws
Administrative Infrastructure
Direct contracts require administrative infrastructure: claims processing (the TPA must be able to process claims under the direct contract rates), member ID cards (members need to know which providers are in the direct contract network), provider directory (members need to find contracted providers), and utilization management (prior authorization and case management for contracted services).
Direct Contracting Platforms
IQ Insight
Direct contracting platforms — technology companies that facilitate employer-provider direct contracts — have significantly reduced the administrative complexity of direct contracting. Platforms like Garner Health, Vera Whole Health, and Bind Benefits provide the technology infrastructure, provider network, and administrative support needed to implement direct contracting without building the infrastructure from scratch.