decisionhealth Newsletters, Answer Books - 2009 Issue 2 (February)
Contracts and Contract Negotiations / Clinical Issues - Some Leeway Allowed
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Article Overview
This article discusses the clinical issues that physician practices and anesthesia-related providers should examine when negotiating managed care contracts. It covers how agreements should define covered and non-covered services, prior authorization responsibilities, utilization review, pain management service approvals, referral and consent questions, and documentation of medical necessity. The piece is relevant for contracting, billing, and compliance staff who need to understand the scope of services and administrative requirements before signing an agreement.
Why This Topic Matters
Clear contract language can affect whether services are treated as covered, whether authorization is required, and whether payment is expected for a given case. Understanding these clinical provisions helps practices reduce avoidable denials and align contract terms with operational workflows.
What You Will Learn
- What clinical issues should be reviewed before signing a managed care contract
- How contracts may address covered and non-covered services
- Why prior authorization and utilization review language matters
- What kinds of responsibility assignments can affect payment for services
- How documentation of medical necessity can be addressed in contract terms
Who Should Read This
- Physician practice administrators
- Anesthesia practice managers
- Medical billing and coding professionals
- Managed care contract negotiators
- Compliance staff
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