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Doody's Review ServiceReviewer: Jeffrey R Leber, MPA (University of Maryland)
Description: This is an excellent primer for providers who are at the point in their practice where they are negotiating contracts with managed care organizations (MCO). The author is an authority in the field and presents a well organized and thoughtful tool. As I read the book, I thought of an old saying my grandmother was fond of: "If common sense was so common, why doesn't everybody have it?" This book is logical in its approach, but not every provider knows the basics and the author makes a point of discussing them. She makes two important points: Any contract that is presented to a provider is a boilerplate that multiple attorneys have reviewed to make sure it limits the fiscal liability of the MCO, not that it's reimbursement-friendly to the provider and, regardless of what the provider wants to revise or amend, the contract should be reviewed by an attorney, because "Only attorneys should talk to other attorneys."
Purpose: This is intended for anyone seeking to negotiate MCO contracts. Although there are many books that strive to meet these objectives, this one is an easy to understand addition to the field. It meets the author's objectives very nicely.
Audience: This book could be used by different audiences for different purposes. First, beginning providers who are not able to negotiate contracts, because they lack clout, will find it useful to understand billing and collections. More established providers who have the bruises of battles with MCOs and know what's wrong with their current contract, will find this book extremely useful in fighting the good fight. The author has worked both sides of the street and presents a balanced view of the field.
Features: The book presents a concise understanding of the basics in billing and collections. It includes sample paragraphs to appeal denials, out of network issues, limiting access, and rejecting a payer's usual and customary fees. It is concise in illustrating the problems with basic contracts and pointing out not only what providers should be mindful of, but also how to maximize the provider's relationship with the payor. Another strength of the book is that it not only explains what may be wrong with a contract, but with the use of precise language, to balance the playing field. It should be noted that not every provider has the ability to renegotiate. Sometimes the provider has to actually provide notice that they will no longer be a provider for the MCO before they get the attention of the MCO. Often the MCO will not react until 80 days of the 90-day required notice of nonrenewal is given.
Assessment: This is a useful tool for beginning providers needing a primer on billing and collections. It is also a worthwhile book for more seasoned providers to actually engage the MCO whether on behalf of a single provider or a larger group. The book differs from other books in the field by attorneys because it is written for providers with cases that they will appreciate in language they will readily understand. The book hits the mark!