Managed Care Contracting
Because most patients are covered by some type of managed care plan, most physicians participate in managed care contracts. Indeed, virtually all health insurance provided by employers is available to individuals in the private insurance market. Increasingly the health coverage provided by public programs, including Medicare and Medicaid, is some type of managed care program.
The AMA has created numerous resources to help physicians involved in negotiating or enforcing these contracts.
Developed by the AMA and state medical association attorneys with expertise in managed care contracting issues and regulations, the NMCC and its supporting database is the most comprehensive managed care contracting tool available to physicians. The NMCC itself includes more than 70 pages of model contract provisions reflecting the country’s most protective managed care laws. The NMCC database includes numerous other helpful resources, including the full text of every single managed care law in the country that regulates the contracting process, the contract or the business relationship between contracted physicians and managed care organizations, and 12 issue briefs covering key contracting issues.
Developed by the AMA and experts in physician payment issues, this series of resources discusses each of the various payment options physicians are now being asked to consider. These guides also set forth the key issues physicians must consider when determining whether to agree to a particular payment system, how to determine a fair price and how to reconcile any payments received to ensure that they are accurate. Make sure you have all the relevant information, whether you are considering a fee-for-service, bundled payment, pay-for-performance, capitation or other payment proposal. And before you agree to any payment system which depends on coming in under budget, make sure you know whether the budget is actuarially sound, and whether your performance will be adequately risk-adjusted.
Is one of your practice’s payers utilizing a rental preferred provider network (PPN)? These arrangements can be complicated and difficult to identify in advance, often depriving a practice of revenue unfairly. Protect yourself by understanding how these networks work.
Medicare Advantage (MA) is a managed Medicare plan administered by a private health insurer. There are several different types of MA plans, and they all have special rules that both physicians and their patients need to understand. Make sure you and your patients don’t get caught off guard.
Although most physicians have several managed care contracts, they will almost always have occasion to treat patients who are covered by a health plan with which they do not contract. The AMA has detailed resources to equip physicians with the knowledge and tools they need to obtain fair payment in these circumstances.
Obtaining, uploading and utilizing contracted fee schedules can be a very complex process, but doing so can save your practice countless hours and hassles down the line.
