Get what you want out of a managed care contract

Why This Topic Matters

Managed care contracts can determine whether services are reimbursed, how disputes are handled, and who bears financial risk when claims are delayed or denied. Understanding the major contract terms helps practices protect revenue and avoid avoidable payment problems.

Article Sections

1. Get what you want out of a managed care contract

   Introduces contract-review concerns for physician practices and outlines the general areas to examine before signing a managed care agreement.

2. Reimbursement policies and procedure coverage

   Discusses how contract language may address service reimbursement, documentation expectations, and whether certain payment-related issues are explicitly included in payer agreements.

3. Know your top 25 procedures

   Focuses on tracking the practice’s most frequently performed services and reviewing how payer fee structures and contracted rates affect them.

4. Bankruptcy, mergers, and medical necessity

   Covers contract risks tied to payer financial changes and the need to understand general medical necessity standards used by the insurer.

5. Use qualified help to negotiate contracts

   Mentions outside resources and professional support options for handling contract negotiation and administration.

6. Appeals process and timely filing/payment

   Addresses contract terms related to denied claims, review of appeals, filing deadlines, and payment timing requirements.