The Managed Care Contracting Handbook Planning Negotiating the Managed Care Relationship 2nd Edition by Maria Todd 1563273691 9781563273698

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Product details:

ISBN 10: 1563273691 

ISBN 13: 9781563273698

Author: Maria K. Todd

Managed care contracting is a process that frustrates even the best administrators. However, to ignore this complexity is to do so at your own expense. You don‘t necessarily need to bear the cost of overpriced legal advice, but you do need to know what questions to ask, what clauses to avoid, what contingencies to cover … and when to ask a lawyer

Table of contents:

1 What Is Managed Care?
2 Managed Care Organizations
HMOs—Health Maintenance Organizations
Federally Qualified HMOs
Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)
HMO Premium Rate Setting
HMO Models
HMO Products
HMO Provider Contracts
Point-of-Service Products in HMOs
Transferring Risk to Providers in the HMO Setting
Preferred Provider Organizations (PPOs)
Silent PPOs
Exclusive Provider Organizations (EPOs)
Physician Organizations
Independent Practice Associations (IPAs)
Physician-Hospital Organizations (PHOs)
Management Services Organizations (MSOs)

3 All-Products Contracts
All-Products Language Example
Incongruence and Inconsistency
Medicare and Medicaid Concerns

4 Dealing with Self-Funded ERISA Payers in Managed Care: Employee Retirement Income Security Act (ERISA) of 1974
Plans to Which These Claims Procedures Apply
Issues outside the ERISA Claims Rules
Regulation Expands Claimants’ Rights and Access to Information
Plan Participants’ Right to Sue under ERISA
Preemption and Interaction of ERISA with State Law
ERISA and State External Review Laws
Timing of Decisions on Claims and Appeals
The Role of the Authorized Representative
ERISA Myths and Realities
Threats Regarding Payment Circumvention to Nonparticipating Providers

5 Medicaid Managed Care
Some Basic Facts
Do Your Homework
Marketing to and Enrollment of Medicaid Recipients
Reimbursement Issues

6 Consumer Driven Health Plans: Contracting Implications
Consumer Driven Health Plans Overview
Payment Cards
Managed Care Contracting Implications
Coordination of Benefits
Stacked Deductibles for Out-of-Network Care
Timely/Prompt Pay Statutes May Be Difficult to Enforce
Probate Implications
No Preauthorization Required
Marketing Materials
Web Site Collaboration
Quality Assumptions
Most Favored Nations

7 Silent Preferred Provider Organizations (PPOs), Secondary Markets, and White Space Management: Three Terms That Translate to Revenue Erosion and Frustration
Secondary Discount Markets
How to Work around Them
White Space Management
Model Language Example

8 Single-Case and Continuous-Discount Arrangements

9 Quality Issues in Managed Care (Pay for Performance)
P4P Contract Terms and Conditions
Best Practices in P4P Contract Disclosures and Terms
Stating Program Objectives

10 Reimbursement Methods in Managed Care
Capitation
Capitation Demographics Analysis
Services
Dealing with Unpredictable and Unmanageable Risk Reinsurance
Dividing the “Pie”
Fee Schedules
Case Rates

11 Strategic Planning for Renewals and New Contracts: Understanding the Changing Competitive Environment
Begin at the Beginning: Define the Task
Who Are Your Competitors?
Forces That Influence Leverage and Competition
Step-by-Step Formulation of Your Competitive Strategy
Response to Competitor Actions
Preemptive Response Questions
Market Segmentation
Pricing
Promotion
Products and Services
Distribution and Logistics
Positioning
Signaling to Your Competition
Developing Alternative Strategies

12 Developing Business Rules for Better Contracts
Precontracting Due Diligence
Model Contracting Policy for Hospitals

13 Negotiation Techniques, Tactics, and Strategies

14 Contract Law Basics
Incorporation of Exhibits or Attachments
Specified Services
Standards of Care
Exclusion of Other Statements
Contract of Record
Express or Implied Contracts
Quasi-Contracts
Definiteness
Termination of an Offer
Duress Issues
Interpretation of Contracts
Unspecified Terms of an Agreement
Assignments
Delegation of Duties
Discharge of Contract
Bankruptcy
Breach of Contract
Liquidated Damages
A Checklist for Managed Care Agreements

15 Evaluating a Managed Care Agreement— Step-by-Step
A Checklist to Guide You
Preliminary Questions
Complete Contract
Identification of the Parties
Fact-Finding Term and Termination
Contact List Provider Relations Contact
Medical Director
Claims Manager
Prior Authorization Contact
Electronic Billing Contact
Precertification/Eligibility Contact
Notice Recipient
Type of Plans Covered by the Contract
Utilization Management Program
Authorizations
Billing and Reimbursement
Capitation
Quality Management
Clinical Quality Issues
Credentialing
Pay for Performance
Term, Termination, and Contract Renewals
Term of the Contract
Termination of the Contract
Assignment of the Contract
Miscellaneous Provisions
Notice
Amendment
Entire Agreement
Dispute Resolution
Organize Your Thoughts
Next Steps

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Tags: Maria Todd, Managed, Contracting, Planning, Negotiating