Top Managed Care Contracting Clauses: A Tool-Kit for Providers / Edition 1

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As a provider, your survival hinges on your ability to maximize reimbursements from managed care contracts and control access to agreed-upon discounts. But money lost at the time of service or through the collection process is often determined well before the patient ever comes through the door. In many cases, that money was lost back when the contract was negotiated. Top Managed Care Contracting Clauses: A Toolkit for Providers contains practical strategies and tools for any organization facing the prospect of negotiating a new managed care contract.

Learn how to eliminate problematic language at the common pain points of a contract by modeling your agreements using these examples and sample clauses. As a bonus, the accompanying CD allows you to download the language and customize it to your specific situation.

Managed care directors, vice presidents of managed care, and contract managers for health-care organizations will benefit from the tools provided in Top Managed Care Contracting Clauses: A Toolkit for Providers. You will learn how to phrase provisions for quickly and accurately resolving payment disputes, handle slow-paying plans, and challenge claims denials or downgrades.

Because every penny counts, you cannot afford to be shortchanged due to a technicality or an oversight in a contract. Let Top Managed Care Contracting Clauses: A Toolkit for Providers be your companion in negotiations.

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Editorial Reviews

Doody's Review Service
Reviewer: 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!
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Product Details

  • ISBN-13: 9781601460691
  • Publisher: HcPro
  • Publication date: 9/1/2007
  • Edition number: 1
  • Pages: 134
  • Product dimensions: 7.00 (w) x 8.90 (h) x 0.40 (d)

Table of Contents

List of figures     vii
About the contributing editor     xi
Introduction     xiii
Approaches to contracting     xiii
How to use this book     xv
Begin at the beginning: A few words about definitions     xvi
Clarifying vague contract language     xviii
Copayments, coinsurance, and deductibles     1
Pushing for 'up-front collections'     3
Seven tips for tackling high-deductible plans     3
Billing and claims     7
Resolving payment problems     7
Contract 'fix' for denials due to delayed discharges     13
Informing the managed care company of its contract violations     14
What happens next?     19
Ensuring prompt payment     21
Prompt-pay remedies     21
Billing the patient     25
Dealing with a plan you suspect is becoming insolvent     27
Denials and claim adjustments     31
Downgrades for services rendered     31
Failing to provide notice or seek certification     35
Dealing with out-of-network and 'silent PPO' issues     39
Problematic 'out-of-network' issues     39
Reviewing single-patient contracts     41
Controlling access to your agreement: Limiting access by 'silent PPOs'     45
Preventing insurers from selling your discounted rates to a silent PPO     46
Rejecting a payer's usual and customary rates     51
Limiting the frequency and scope of audits     55
Dealing with audit requests     55
Coordinating self-insured payer audits     60
Procedure for offsetting overpayments     61
Mediation, arbitration, and appeals     63
Spelling out the dispute-resolution processes     63
Allowing for informal dispute resolution     67
Resolving a dispute over price or value     70
Planning your patient communication strategy     75
Controlling the products accessing your agreements     79
Tailoring your agreement for specific products     81
Ensuring contracts set differences among plan products     86
Seven tips to tackle high-deductible plans     87
Imposing due-diligence requirements     89
Transparency of pricing and quality information     95
Controlling your confidential information: A list of questions to consider     95
Defining and disclosing rate information     97
Pricing and specific payment issues      99
Protecting your ability to offer new services at a reasonable rate     99
Negotiating rates to limit the risks the provider assumes     106
Providing and getting paid for online consults     107
Getting properly paid for implantables and high-cost prescriptions     110
Emergency preparedness     111
Miscellaneous clauses     117
Limiting the scope of an indemnification clause     117
Negotiating preauthorization requirements     121
Establishing 'effective dates'     125
Ensuring regulatory approval     127
Dealing with applicable laws and changes to laws     128
How to use the files on your CD-ROM     131
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