October 10, 2011. Leslie A. Allen firstname.lastname@example.org 205.250.6655. Managed Care Contracts. I. Background: Managed Care. What do we mean by “managed care”?
Do you get to choose which MCOs with which to contract?
The New Role for Physicians in a Managed Care World
Due Diligence in Negotiating the Managed Care Contract
1. Know the TERM of your contract.
2. Know TERMINATION provisions – TWO KINDS: with and withoutcause:
B. Does the contract allow termination “with cause” in the event of a material breach?
C. Know what DUE PROCESS, if any, the MCO is obligated to afford.
3. Know the RENEWAL terms – Evergreen Provisions
4. Pay attention to the contract’s definition of EMERGENCY SERVICES:
5. Know the criteria used to determine MEDICAL NECESSITY and what recourse you have to challenge denials.
To what extent can the MCO use cost considerations as part of the medical necessity criteria?
The preferred definition of “medical necessity”/”medically necessary” in the managed care contract is as follows:
Know the process for challenging the MCO’s determination that a service is not medically necessary.
6. Determine whether the managed care agreement contains an ALTERNATIVE DISPUTE RESOLUTION or ARBITRATION provision.
Some believe there are benefits to arbitration when compared to litigation:
Potential Problems with Arbitration Provisions:
7. Be aware (and beware) of HOLD HARMLESS / INDEMNIFICATION provisions.
Leslie A. Allen