by Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
July 31st, 2014
It is apparent as the healthcare changes so does Managed Care contracts. You need to be more aware, they are more complex than ever and can be confusing, take heed as you enter into a new contract as a participating provider. Below are just a few issues to be sensitive to and is in no way inclusive of everything you need to be aware of.
- Verify which products you are agreeing to; are there multiple plans under the same contract? If so be sure they are all beneficial to your practice.
- Be aware of Silent PPO’s – a silent PPO is when your fees are discounted by a plan that the physician did not contract, A plan may have several Third Party administrator with multiple plans.
- What about the Fee-Schedule; does the contract state the fees can change at the sole discretion of the plan?
- Can you re-Assign your contract if you sell or merge your practice?
- Do you completely understand the provisions of the contract, be sure they are not vague, or excessively strict. You may perhaps want to discuss a more favorable language during the contracting process so it is completely clear.
- Does the plan that have the final authority on medical necessity issues?
- What are the ramifications of the contract, is it in your favor?
If you are a Member of the AMA, you may want to consider the National Managed Care Contract (NMCC) Database as a resource. This tool produced by the AMA is designed to ensure managed care contracts comply with the managed care laws of all 50 states, and are not one sided. They will also assist you in your negotiation of Managed Care Contracts. Visit NMCC here.
Be sure to educate your office staff to ensure contractual agreements are being followed as well. If you are unaware of your contractual obligations on previously signed contracts don’t hesitate to contact your provider representative. Keep in mind some of your previous contracts may have addendums you agreed to by not disagreeing.
My final suggestion: Physicians should seek advice from an attorney with experience representing physicians prior to signing a managed care contract!