Negotiating with Managed Care Organizations

1. Negotiating with Managed Care Organizations

2. Checklist for Negotiating a Managed Care Contract • Know your costs • Know your capacity • Define your competitive advantages • Know your market & define it for each MCO • Understand the requirements & standards of each MCO

3. Checklist for Negotiating a Managed Care Contract • Formulate each contract in terms of definitive levels of service • Maintain patient opinion data regarding the services your organization provides • Learn the level of ethical commitment of each MCO with which you are negotiating

4. Checklist for Negotiating a Managed Care Contract • Have factual data in hand at the time of your first meeting with the MCO • Assure that your organization establishes the precedent(s) forsubsequent negotiations

5. Questions to Improve Negotiating Strategy with MCOs (keywords) • Registered • Board members - who & how elected • B.M. specialties - references • Employer groups - can we contact • Number of counties in the state & # of states • Share types of contracts • MCO carry professional liability for providers • Require providers carry professional liability insurance - how much • Insurance products of MCO valid & legal

6. Questions to Improve Negotiating Strategy with MCOs (keywords) • UR/QA activities • MCO litigation history • MCO investigated • Blank spaces in contracts - explain • Termination • Termination notice requirements • Documents not reviewed but referenced in agreement • Mutual hold harmless agreement • Exclusive contracts

7. Questions to Improve Negotiating Strategy with MCOs (keywords) • Restrict referrals • Unilateral amendment of contract • Contract clauses & state law • Individual physician agreements - even in groups • Arbitration requirements & effect on professional liability coverage • Termination impact on doctor-patient relationship • Confidentiality proprietary information

8. Questions to Improve Negotiating Strategy with MCOs (keywords) • Cost effective & quality services • Oral representations • Limits on physician’s professional judgment • Time limit claims submission • Timing guarantee claims payment • Interest payment & delayed reimbursement • Verify eligibility • Contract identification of non-covered services • Patient liability for payment of non-covered services

9. Questions to Improve Negotiating Strategy with MCOs (keywords) • Use physician names on brochures • Prior authorization • Modify office procedures • Provision of services after contract is terminated • Change of fee schedule by MCO • Substitute physician when away • Unspecified medical policies • Unilateral alteration of standards of care • Qualifications referral physicians

10. Questions to Improve Negotiating Strategy with MCOs (keywords) • Exclusion of specific specialty services • Gatekeeper • Indemnification provisions - difference between hold harmless & indemnification provisions • Contract interfere with sound judgment • Assumption of liability for payments after patient terminates without notifying provider • Contract renewed automatically • Underwriters length of time with company • Can practice limit participation of new members

11. Questions to Improve Negotiating Strategy with MCOs (keywords) • NCQA accreditation status • Reinsurance provided for catastrophes - specific with aggregate

12. Negotiating Posture & Tactics

13. Negotiating Posture • Be organized • Spokesperson • Be confident • Being persuasive vs. first being persuaded • Be prepared • Advance preparation • Rehearsal • Thinking on your feet

14. Negotiating Posture • Be ambitious • Person with higher expectations wins • Be determined • Must ask to get • Be positive • Confidence shows • So does haughtiness & rudeness

15. Negotiating Posture • Be cautious • Opponent may read same things you do • Be courteous • No bad manners or personal attacks • Be reasonable • Don’t be stubborn • Deadlocks come from 2 people disagreeing • Mostly unnecessary

16. Negotiating Posture • Don’t assume • Everything is open to negotiation • Don’t annoy • Learn first names • Don’t posture • Impressing others & showing off • Don’t let down your guard • “Let’s have dinner”

17. Negotiating Posture • Recognize & gracefully accept success when it comes to you

18. Negotiating Tactics • Seize the initiative • Choose your issues of import • Host session if possible • Choose break times • Adjournment • Location of lighting • Home field advantage

19. Negotiating Tactics • Emphasize common objectives • Open channels of communication • Remember the need to save face • One upmanship • Demonstrate unreasonableness of opponent’s position • No personal attacks

20. Negotiating Tactics • Use questions & hypotheticals • Use to learn needs & sticking points of opposition • Sometimes best to say nothing • Rely on controlled body language • Brevity is the soul of success • Never interrupt • Basic courtesy • Opponent may give useful information

21. Negotiating Tactics • Make notes • Gives you time to think • Thoughtful timing • Wait for right moment to seize the initiative • Issues you can concede • Go for “win-win” • Reduce final agreement to writing • Memo of understanding

22. Managed Care Facts & Figures

23. Facts & Figures • See overheads