The Managed Care Contracting Handbook, 2nd Edition: Planning & Negotiating the Managed Care Relationship

by Todd, Maria K.

• ISBN13: 9781563273698
• ISBN10: 1563273691
• Edition: 2nd
• Format: Hardcover
• Copyright: 2009-03-26
• Publisher: Productivity Pr

Summary

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. Newly updated to help you anticipate and navigate the latest roadblocks, the second edition of Maria Todd's The Managed Care Contracting Handbook will help you cut through the morass of paper tigers that keep you and your agency from realizing the funding that is yours.

Table of Contents

Acknowledgments	p. ix
Introduction	p. xi
What Is Managed Care?	p. 1
Managed Care Organizations	p. 3
HMOs-Health Maintenance Organizations	p. 4
Federally Qualified HMOs	p. 4
HMO Premium Rate Setting	p. 6
HMO Models	p. 7
HMO Products	p. 9
HMO Provider Contracts	p. 9
Point-of-Service Products in HMOs	p. 9
Transferring Risk to Providers in the HMO Setting	p. 10
Preferred Provider Organizations (PPOs)	p. 11
Silent PPOs	p. 13
Exclusive Provider Organizations (EPOs)	p. 14
Physician Organizations	p. 14
Independent Practice Associations (IPAs)	p. 15
Physician-Hospital Organizations (PHOs)	p. 16
Management Services Organizations (MSOs)	p. 17
All-Products Contracts	p. 21
All-Products Language Example	p. 22
Incongruence and Inconsistency	p. 23
Medicare and Medicaid Concerns	p. 26
Dealing with Self-Funded ERISA Payers in Managed Care: Employee Retirement Income Security Act (ERISA) of 1974	p. 29
Plans to Which These Claims Procedures Apply	p. 30
Issues outside the ERISA Claims Rules	p. 30
Regulation Expands Claimants' Rights and Access to Information	p. 32
Plan Participants' Right to Sue under ERISA	p. 32
Preemption and Interaction of ERISA with State Law	p. 34
ERISA and State External Review Laws	p. 35
Timing of Decisions on Claims and Appeals	p. 35
The Role of the Authorized Representative	p. 36
ERISA Myths and Realities	p. 39
Threats Regarding Payment Circumvention to Nonparticipating Providers	p. 42
Medicaid Managed Care	p. 45
Some Basic Facts	p. 46
Do Your Homework	p. 49
Marketing To and Enrollment Of Medicaid Recipients	p. 53
Reimbursement Issues	p. 54
Consumer Driven Health Plans: Contracting Implications	p. 55
Consumer Driven Health Plans Overview	p. 55
Payment Cards	p. 59
Managed Care Contracting Implications	p. 59
Coordination of Benefits	p. 59
Stacked Deductibles for Out-of-Network Care	p. 60
Timely/Prompt Pay Statutes May Be Difficult to Enforce	p. 60
Probate Implications	p. 61
No Preauthorization Required	p. 61
Marketing Materials	p. 61
Web Site Collaboration	p. 62
Quality Assumptions	p. 62
Most Favored Nations	p. 62
Silent Preferred Provider Organizations (PPOs), Secondary Markets, and White Space Management: Three Terms That Translate to Revenue Erosion and Frustration	p. 63
Secondary Discount Markets	p. 64
How to Work around Them	p. 66
White Space Management	p. 67
Model Language Example	p. 74
Single-Case and Continuous-Discount Arrangements	p. 77
Quality Issues in Managed Care (Pay for Performance)	p. 81
P4P Contract Terms and Conditions	p. 84
Best Practices in P4P Contract Disclosures and Terms	p. 88
Stating Program Objectives	p. 90
Reimbursement Methods in Managed Care	p. 91
Capitation	p. 92
Capitation Demographics Analysis	p. 92
Services	p. 93
Dealing with Unpredictable and Unmanageable Risk Reinsurance	p. 93
Dividing the "Pie"	p. 95
Fee Schedules	p. 98
Case Rates	p. 99
Strategic Planning for Renewals and New Contracts: Understanding the Changing Competitive Environment	p. 107
Begin at the Beginning: Define the Task	p. 110
Who Are Your Competitors?	p. 111
Forces That Influence Leverage and Competition	p. 112
Step-by-Step Formulation of Your Competitive Strategy	p. 114
Response to Competitor Actions	p. 115
Preemptive Response Questions	p. 116
Market Segmentation	p. 117
Pricing	p. 118
Promotion	p. 118
Products and Services	p. 118
Distribution and Logistics	p. 118
Positioning	p. 118
Signaling to Your Competition	p. 120
Developing Alternative Strategies	p. 121
Developing Business Rules for Better Contracts	p. 125
Precontracting Due Diligence	p. 126
Model Contracting Policy for Hospitals	p. 131
Negotiation Techniques, Tactics, and Strategies	p. 137
Contract Law Basics	p. 143
Incorporation of Exhibits or Attachments	p. 145
Specified Services	p. 145
Standards of Care	p. 145
Exclusion of Other Statements	p. 145
Contract of Record	p. 146
Express or Implied Contracts	p. 146
Quasi-Contracts	p. 146
Definiteness	p. 147
Termination of an Offer	p. 150
Duress Issues	p. 150
Interpretation of Contracts	p. 150
Unspecified Terms of an Agreement	p. 151
Assignments	p. 152
Delegation of Duties	p. 152
Discharge of Contract	p. 153
Bankruptcy	p. 154
Breach of Contract	p. 155
Liquidated Damages	p. 156
A Checklist for Managed Care Agreements	p. 156
Evaluating a Managed Care Agreement-Step-by-Step	p. 163
A Checklist to Guide You	p. 163
Preliminary Questions	p. 166
Complete Contract	p. 167
Identification of the Parties	p. 168
Fact-Finding	p. 169
Type of Plans Covered by the Contract	p. 172
Utilization Management Program	p. 173
Authorizations	p. 177
Billing and Reimbursement	p. 179
Quality Management	p. 185
Term, Termination, and Contract Renewals	p. 188
Miscellaneous Provisions	p. 191
Organize Your Thoughts	p. 193
Next Steps	p. 194
Notes	p. 196
Frequently Asked Questions	p. 197
Appendix: Insurance and Managed Care Glossary	p. 199
Index	p. 317
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