Managed Care Contracting Webinar Series
Now, in a post-health care reform world where managed care organizations (MCOs) are rapidly and permanently changing the way they pay and otherwise do business with physicians, it is imperative that you are able to negotiate and conduct business in a way that preserves your rights and maximizes your ability to reach your short- and long-term goals. This series of webinars will empower physicians and practice staff to do just that.
To help you meet the challenges of contracting activities in an environment where physician payment and delivery models are rapidly changing, the American Medical Association's(AMA) Practice Management Center has launched a LinkedIn group—the AMA Practice Efficiency & Management Group.This group is designed to encourage dialogue on a wide variety of issues—from contracting strategies, to billing and payment, to making the most of administrative automation—to help your practice run efficiently. AMA Practice Efficiency & Management LinkedIn Group today. If you don’t have a LinkedIn account, you can open one for free here.
View all of the archived webinars and access related issue briefs on the following “hot topics” that are essential to achieve success in managed care contracting:
As physicians face the transformation of the health care payment and delivery system, it is imperative that physicians read and understand contract amendments before signing on the dotted line. Understanding new contract terms will only help your practice, even if you believe you lack bargaining power. The webinar includes a discussion and demonstration of the AMA’s one-of-a-kind, comprehensive and empowering National Managed Care Contract (NMCC) database, which will show how simple it is to use this resource to help your practice adapt to an evolving health care landscape. It concludes with a brief description of the upcoming contracting “hot topics” that will be discussed in subsequent webinars. The discussion also highlights other related AMA resources, such as “ACO, CO-OPs and other options: A ‘how to’ manual for physicians navigating a post-health reform world, 2nd edition,” and “Evaluating and negotiating emerging payment options.”
Understanding the new ways physicians are being paid and the related transformation taking place in managed care contracting is crucial but will not by itself ensure your long-term success. In order to thrive in this evolving environment, your practice needs to be able to effectively negotiate contracts with managed care organizations. Negotiation is as important for your practice to understand as the details of new payment options, so your practice should plan to equally prepare for both. Without balancing your knowledge of new payment options with a fundamental understanding of negotiation, your practice may not be fully prepared. This webinar will help you plan for the negotiation process and give you strategies that others have found useful in managed care contract negotiations.
- Issue Brief 1- Fundamentals of Negotiating the Deal
- Evaluating & negotiating emerging payment options: Chapter 11, Negotiating the Deal
“Budget-based” payment systems include most of the new payment models designed to incentivize value rather than volume. These include capitation, bundled payment and shared savings arrangements, as well as those pay-for-performance systems that are based on achieving certain cost targets or outcomes, rather than on simply reporting whether certain activities were done. Under budget-based payment systems, rather than being paid for each service provided, physician income is tied to the physician’s ability to successfully predict future utilization for a patient population, by thoroughly understanding the past utilization for a similar patient population, as well as how much it costs the practice to deliver those services. Successful navigation of budget-based payment systems requires mastery of concepts more commonly associated with health insurance than physician payment, including “actuarial soundness,” “risk adjustment” and “risk mitigation.” This webinar describes the key issues associated with budget-based payment systems and equips your practice with the tools you will need to succeed and thrive under these systems.
- Issue brief 2: Understanding and Evaluating Budget-based Payment Systems
- Evaluating & negotiating emerging payment options:Chapter 1, How to Establish Your Baseline Costs
- Evaluating & negotiating emerging payment options: Chapter 10, Working with Actuaries
All budget-based payment systems link at least some portion of physician payment to the physician’s assumption of risk for losses or overutilization. For example, in a shared savings arrangement, physicians may share risk of loss with the managed care organization, but in a capitated arrangement, may assume full risk for the utilization of their professional services. Physicians will not be able to monitor and manage assumed risk successfully unless the managed care organization regularly provides physicians with complete and accurate data reports concerning patient utilization, performance with respect to quality and efficiency measures, patient eligibility, etc. Physicians must also receive specific Division of Financial Responsibility Matrices and end-of-year claims reports that will enable them to perform claims and payment reconciliations. This webinar identifies the types of information that your practice will need from managed care organizations to monitor and manage risk, and outlines the rights your practice may have under state law to receive that information.
Even if budget-based payment systems ultimately replace fee-for-service (FFS) as the predominant means of physician payment, FFS will certainly play a major role during the transitional period from FFS to those systems, both as a benchmark against which physicians will want to evaluate alternative budget-based payment models and as a portion of physician payment, e.g., if specific services are “carved out” of the budget-based payment arrangement. It remains vital, then, that managed care organizations provide your practice with sufficient to help you understand fully how much you will receive for your services on a FFS basis. This webinar describes the types of information that you will need to obtain from the managed care organization, and the rights to that information that many states have given to physicians.
- Issue brief 4: Disclosure of Payment-Related Information Relative to Fee-for-Service
- Evaluating & negotiating emerging payment options:Chapter 2, Fee-for-service issues
A managed care organization’s (MCO) claims submission and payment requirements and procedures may be highly detailed and complicate your ability to receive accurate and timely payment for your fee for service claims. For example, MCOs have in the past engaged in either “no or slow” payment as a means of improving their bottom line by decreasing, or earning interest income on, physician payments. Fortunately, every state has implemented legal requirements that protect physicians and help ensure that physicians are treated fairly. For example, all states impose deadlines within which MCOs must pay or deny clean or complete claims and provide remedies when MCOs fail to timely and appropriately process physician claims. This webinar discusses your right to be treated fairly with respect to claims processing and the remedies that may be available to you when an MCO does not treat you accordingly.
- Issue brief 5: Claims submission, processing, payment and remedies
- Prompt payment template letters
- Payer-specific information
- Take action if an insurer is engaging in unfair business practices
- Prepare, follow and appeal that claim
Coordination of benefits (COB) continues to frustrate many physicians. Sometimes this is due to confusion about the COB rules themselves, e.g., how dual coverage for dependents of married couples or dependents of divorced or separated couples fits into the mix. But sometimes payers themselves can greatly complicate a physician’s ability to be paid timely. For example, when two payers involved maintain that the other payer is “primary,” the physician often has to “wait it out” until the payers resolve that dispute. Unfortunately, by the time resolution has been achieved, the deadline for claims submission to the secondary payer has often passed and that payer will refuse to accept the claim. This webinar discusses strategies that some of your peer physicians have found helpful when dealing with COB complications, including situations in which payers dispute priority. The webinar also helps clarify confusion by describing some of the common COB rules that can facilitate payment, e.g., the so-called “birthday rule.”
Managed care organizations’ (MCO) overpayment recovery efforts have plagued physicians for far too long. MCOs (or the third parties that they hire to perform these recovery efforts) frequently seek refunds of payments made years in the past, of which the physician may have little, if any, records. And many refund requests provide little, if any, identifying information, such as the patient’s name or identification number, dates of service, payment amounts, the name or national provider identifier (NPI) of the physician who provided the service, etc., that would enable the physician to investigate the alleged overpayment’s legitimacy or make crucial accounting adjustments. If the physician refuses to refund the alleged overpayment, MCOs simply recoup that amount from pending or future claims. This webinar discusses state laws that protect physicians and regulate MCOs’ ability to pursue overpayments, by, for example: restricting the “look back,” period; imposing requirements that refund requests must satisfy; and limiting the circumstances under which an MCO may pursue an alleged overpayment.
- Issue brief 7: Overpayments and Underpayments
- Webinar: Private payer audits - What you need to know
- Webinar: Medicare and Medicaid audits - What physicians need to know
- How to perform a physician practice internal billing audit
- How to prepare for a health insurer retrospective audit
- Letter notifying insurers of overpayment
- Letter indicating payment to patient and disclaiming further refund obligation
In general, an all products clause (APC) requires the physician to participate in all of the products or plans offered by the managed care organization (MCO), currently or in the future. These products may include a health maintenance organization (HMO), preferred provider organization (PPO), workers’ compensation, automobile personal insurance, Medicare and/or Medicaid managed care, high deductible health plans, or self-funded employee health benefit plans or products. APCs can be problematic for physicians for several reasons. Many managed care contracts do not specify the products in which the physician will be required to participate, and the physician cannot refuse to participate in a product unless he or she terminates the agreement. Particular products may have administrative requirements that increase the practice’s “hassle factor” and cost of doing business, or different fee schedules. The MCO may also want to pay your practice under a single fee schedule for all of its products, even though a fee schedule that may be acceptable for some product types may be wholly inadequate for others. This webinar discusses APCs, state law rights that may be available to you, and strategies that some physicians have found useful in dealing with APCs.
Managed care contracts frequently permit managed care organizations (MCO) to rent their rights to negotiated physician discounts to third parties. These third parties may be payers other than the MCO. But these third parties may also be nonpayers such as “repricers,” network brokers, or rental network preferred provider organizations (PPO), which do not sponsor or administer health benefit plans but collect information concerning physician negotiated discounts. They then sell that information to MCOs with which the physician may, or may not, have a direct contractual relationship. When the physician submits a claim for payment to an MCO, the repricer, network broker, or rental network PPO reduces the claim payment by the deepest contractual discount to which the physician has agreed and to which the rental network PPO, repricer, or network broker has access. In many cases, the physician may not realize that a nonpayer has applied his or her negotiated discounts to claims payments until the practice receives an explanation of benefits or remittance advice listing unrecognized entities and payment rates representing the lowest discounts that the practice has agreed to accept. This webinar helps your practice identify contract language that allows MCOs to rent their discounts. The webinar discusses state laws that restrict rental network activity and tools your practice can use to counter discount rental activities.
Verification refers to the process managed care organizations (MCO) use to determine whether a patient is eligible to receive covered services under a health benefit plan. MCOs frequently make verification errors, e.g., representing to physicians that patients are eligible to receive services when, in fact, they are not eligible. The MCO itself may be responsible for these errors. Or the error may stem from the MCO not having up-to-date eligibility information. For example, although the MCO may have issued a verification based on information showing that the patient was employed by Company A, Company A may not have forwarded on to the MCO the most recent eligibility information indicating that, at the time of the verification, Company A no longer employed the patient. Mistaken verifications are a recurrent problem for physicians, because MCOs often contractually transfer the financial risk of erroneous eligibility verifications to physicians, meaning that MCOs may seek refunds from physicians who provided services to patients after erroneous verifications. This webinar helps your practice identify this “risk transfer” language in your contracts, and describes steps you can take to reduce that risk and any state-law based protections available to your practice.
Most, if not all, states have adopted extensive regulatory schemes imposing specific requirements on the utilization review processes that fully insured Employee Retirement Income Security Act (ERISA) employee health benefit plans and non-ERISA plans use to determine whether or not an item or service is medically necessary. The U.S. Department of Labor (DOL) has adopted an extensive regulation governing the utilization review processes used by both fully-insured and self-insured ERISA plans. Pursuant to the Patient Protection and Affordable Care Act of 2010, the DOL recently incorporated additional patient/physician protections into its utilization review regulation. This webinar describes common state-based utilization review protections, the DOL regulation and its recent pro-physician/patient amendments, and how your practices can make the most effective use of state and federal utilization review rights.
Managed care agreements typically permit the managed care organization (MCO) to unilaterally amend the agreement (in addition to extracontractual documents such as policies and procedures that may affect contractual rights and obligations). Physicians need to understand clearly the circumstances under which the MCO may amend the managed care contract, as the MCO’s ability to amend the contract may have a significant negative effect on the physician, e.g., if the amendment causes a reduction in the physician’s payment. Many agreements do not require the MCO to provide advance notice of proposed contractual changes. And even if the agreement requires such notice, the MCO is rarely required to give the notice in a way that is likely to attract the physician’s attention. For example, the MCO may be free to list the proposed amendment within a multitude of unrelated and/or inessential information on a website. This webinar discusses how to identify and evaluate contract amendment language; provides possible language you might use to avoid the effects of a disadvantageous amendment; and discusses the state law-based rights that might provide additional amendment-related protections.
The relationship between physicians and managed care organizations (MCO) is becoming increasingly complex and adversarial. Physicians continue to complain about a broad range of unfair MCO business practices. When contracted physicians and MCOs come to an impasse over these business practices, physicians and MCOs often attempt to resolve disputes through “alternative dispute resolution” (ADR) mechanisms. “Alternative dispute resolution” generally refers to any means of resolving disputes other than litigation. Mediation and arbitration are the two most common forms of ADR, and of these two, arbitration appears much more frequently in managed care agreements. From a physician perspective, ADR can in some cases be a more effective means of dispute resolution than litigation, assuming the ADR process is structured appropriately. This webinar describes the general characteristics of ADR (particularly arbitration) and how ADR contrasts with litigation, how to avoid traps for the unwary in contractual ADR clauses, and the kinds of ADR structures than some physicians have found to be the most useful.
All managed care contracts have provisions addressing the agreement’s term, termination, and renewal. Although the term typically ranges from one to three years, the agreement’s termination and renewal provisions may significantly reduce or expand the time period during which the agreement is in force. Termination provisions may allow the managed care organization to cancel the agreement on very short notice, forcing physicians to scramble to find alternative sources of practice revenue. Termination language may significantly complicate a physician’s ability to get out of a contract when the business relationship becomes detrimental. This webinar helps your practice identify problematic term, termination, and renewal language, and provides alternative language that might be more protective of physician interests. The webinar also describes some of the pre-termination due process rights that you may want to consider including as part of your managed care contract, and also includes a discussion of the due process rights that may well be available to you under state law.
In addition to the problematic contract clauses or “hot issues” that have been highlighted in previous webinars, this final webinar talks about a number of remaining managed care contract clauses that have caused problems for many physicians. These other clauses include most-favored nation, hold-harmless, indemnification, limitation on liability, limitation on damages, and so-called “gag” clauses. This webinar explains the effect of each of these clauses, and shows your practice how to identify these clauses when they appear in a managed care contract offered to you. The webinar describes steps many states have taken to prohibit, or at least restrict, use of these clauses, and shows your practice how to use the NMCC and NMCC database to determine what rights might be available to you.