Managed Care FAQs

by  Wyn Staheli, Director of Research
August 4th, 2014

The following frequently asked questions (FAQs) are adapted from the American Pyschiatric Association (APA).  It is relevant to all types of providers with questions about managed care.

Q:  I am having a problem getting in the network of managed care company X.  They have a contract with a major employer in the area, so it is important for me to be able to join this network.  What should I do?

A:  When applying for admission to this network, stress your unique skills in treating specific populations and your expertise and willingness to do partial hospitalizations or inpatient when required.  Any other outstanding qualities of your practice, such as flexible hours, knowledge of different languages and cultures, and experiences with other MCOs (i.e., demonstrating that you are managed care savvy) should be emphasized too.  If you are currently treating patients for this employer, have the patients write to the managed care company requesting your continued services.  If you are refused, apply again when the network opens. 

Q:  What are the common elements to look for in a managed care contract?

A:  Have a lawyer review the contract.  Pay special attention to term and termination provisions, risk allocation and liability, insurance coverage and limits, hold harmless provisions, confidentiality provisions, compensation provisions, provider obligations, party’s covenants or the rights and responsibility of each party in maintaining the contract, utilization review requirements, etc.

Q:  Should I sign a contract with the “hold harmless clause”?

A.  Do not sign a contract with the “hold harmless clause” unless it is reviewed by a lawyer.  It may adversely affect your malpractice insurance.  You may report the problem to the local District Branch (DB) and have them negotiate a modification or elimination of the clause (some DBs have been successful in doing this), or report the problem to the APA so we can negotiate with the company on your behalf.  You may also cross out and initial your elimination of the clause if the rest of the contract is satisfactory to you.  Some companies may allow this.  You could also join the Legal Consultation Plan for a nominal fee.  For an additional annual fee, they will review a fixed number of contracts per year.  Please call (202) 682-6000 for additional information on the services offered by the plan.

Q:  Company “A” will only reimburse me for medication management and not psychotherapy.  What should I do?

A:  Most companies will allow you to negotiate coverage for psychotherapy and medication management if the case is complicated and needs follow-up by the same provider.  If you have this policy in writing, please send it to the Office of Economic Affairs and Practice Management.

Q:  What do managed care organizations look for when selecting a provider?

A:  The following are important considerations for MCO selection and retainment of providers:

Managed Care FAQs. (2014, August 4). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/managed-care-faqs-34841.html

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