Managed Care Contract

Introduction

The base of any managed care contract should be the welfare of the patient and the covered employees. Physician use the knowledge, skills, defined, process to coordinate health care for the patient. The success of the contracts depends upon how the base relationship is valued, developed and nurtured. The contract left the physician vulnerable to the challenges posed by the changing health care environment. Managed care contracts came in varieties, more or less the language of the contract are same and standard one. Standard language should be preferred because they are market driven.

Management should consider the something before reviewing the contract

1. How many other providers have signed this particular agreement?

2. Are they willing to be used as references?

3. Which sections of the contract have been modified over time? (The plan may or may not agree to share this information).

4. Has this contract been reviewed by the state's largest malpractice carrier? Request a copy of those comments.

The contract review checklist should considered the following

1.	Request a copy of all policy and procedure manuals specified in the contract.
2.	Request that the contract specialist walk through the manuals with your office staff.
3.	Understand the referral authorization procedure.
4.	Understand the reporting requirements. Obtain samples of the required format for utilization reporting.
5.	Determine if there are any special requirements, such as the use of specific ambulatory surgery centers.
6.	Determine what the penalties are when these procedures are not followed.
7.	Obtain a list of participating physicians.
8.	Obtain a list of the specialty physician network: those on a fee for service basis vs. a capitation rate.
9.	Request a list of the ancillary providers (home health, skilled nursing, etc.).
10.	Determine the pharmacy coverage and if a formulary exists, obtain a copy of it.
11.	Obtain a contact address and telephone list of pertinent MCO staff, including the contract specialist team, utilization management staff, customer service, the provider service representative assigned to your service area, and the Medical Director. These contacts should be easily accessible to the office staff.
12.	Determine quality assurance requirements: Are you required to participate in any committee functions?

Top management should check this clause in the agreement properly

The review process should be cross check all the important terms of the agreement

Review of the Parties- This sector considers the players, the physician, physician group, or other provider, and the insurer.

Medical Services Provided – It contain detail instruction regarding the services provided in the contract. If the new services has to add or removed it has to be given standard time notice.

Location of Services. It considers the full addresses to ensure accurate marketing of services.

Policy and Procedures- All the policy and procedure in the contract should be updated as per industry current norms to meet the government rules and regulations.

Credentialing Standards- Standards such as HCFA, NCQA (National Committee for Quality Assurance) should be included in contracts.

Medical Records- MCOs must have access to all medical records as they include members' medical service while covered.

No Recourse Against Patient- Patient should be protected from dispute between the Plan, the employer groups, and the physicians.

 Liability coverage- It contain all detail of  general and professional liability including compensation plan.

Member grievance- A Member Grievance Committee established by an MCO accept or denies the claims.

Arbitration- Agreement should contain an arbitration clause to deal with unresolved issues.

Effective dates- Contracts contains that the agreement will not be effective until credentials are approved and both parties have executed the agreement.

Term and Termination- Usually one-year period is of contracts, after that it is subject of renewal.  Commonly, there is a 90-day out clause by either party with or without cause or reason, what really means that the contract is only a 90-day agreement

Conclusion

After verifying that all terms and conditions are included in the agreement, the managed should also consider the ethical standards is followed apart from the legal obligations.

 References

Ludmerer, K. M. (2005). Time to heal: American medical education from the turn of the century to the era of managed care. Oxford University Press.

Margaret Edmunds, Institute of Medicine (US). Committee on Quality Assurance, & Accreditation Guidelines for Managed Behavioral Health Care. (1997). Managing managed care: quality improvements in behavioral health. National Academies.

Shortell, S. M., Gillies, R. R., & Anderson, D. A. (1994). The new world of managed care: creating organized delivery systems. Health affairs, 13(5), 46-64.

Kerr, E. A., Mittman, B. S., Hays, R. D., Siu, A. L., Leake, B., & Brook, R. H. (1995). Managed care and capitation in California: how do physicians at financial risk control their own utilization?. Annals of Internal Medicine, 123(7), 500-504.