The Managed Care Contracting Handbook, 2nd Edition: Planning & Negotiating the Managed Care Relationship
by Todd, Maria K.Edition: 2nd
Format: Hardcover
Pub. Date: 2009-03-26
Publisher(s): Productivity Pr
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Summary
Managed care contracting is a process that frustrates even the best administrators. However, to ignore this complexity is to do so at your own expense. Newly updated to help you anticipate and navigate the latest roadblocks, the second edition of Maria Todd's The Managed Care Contracting Handbook will help you cut through the morass of paper tigers that keep you and your agency from realizing the funding that is yours.
Table of Contents
| Acknowledgments | p. ix |
| Introduction | p. xi |
| What Is Managed Care? | p. 1 |
| Managed Care Organizations | p. 3 |
| HMOs-Health Maintenance Organizations | p. 4 |
| Federally Qualified HMOs | p. 4 |
| HMO Premium Rate Setting | p. 6 |
| HMO Models | p. 7 |
| HMO Products | p. 9 |
| HMO Provider Contracts | p. 9 |
| Point-of-Service Products in HMOs | p. 9 |
| Transferring Risk to Providers in the HMO Setting | p. 10 |
| Preferred Provider Organizations (PPOs) | p. 11 |
| Silent PPOs | p. 13 |
| Exclusive Provider Organizations (EPOs) | p. 14 |
| Physician Organizations | p. 14 |
| Independent Practice Associations (IPAs) | p. 15 |
| Physician-Hospital Organizations (PHOs) | p. 16 |
| Management Services Organizations (MSOs) | p. 17 |
| All-Products Contracts | p. 21 |
| All-Products Language Example | p. 22 |
| Incongruence and Inconsistency | p. 23 |
| Medicare and Medicaid Concerns | p. 26 |
| Dealing with Self-Funded ERISA Payers in Managed Care: Employee Retirement Income Security Act (ERISA) of 1974 | p. 29 |
| Plans to Which These Claims Procedures Apply | p. 30 |
| Issues outside the ERISA Claims Rules | p. 30 |
| Regulation Expands Claimants' Rights and Access to Information | p. 32 |
| Plan Participants' Right to Sue under ERISA | p. 32 |
| Preemption and Interaction of ERISA with State Law | p. 34 |
| ERISA and State External Review Laws | p. 35 |
| Timing of Decisions on Claims and Appeals | p. 35 |
| The Role of the Authorized Representative | p. 36 |
| ERISA Myths and Realities | p. 39 |
| Threats Regarding Payment Circumvention to Nonparticipating Providers | p. 42 |
| Medicaid Managed Care | p. 45 |
| Some Basic Facts | p. 46 |
| Do Your Homework | p. 49 |
| Marketing To and Enrollment Of Medicaid Recipients | p. 53 |
| Reimbursement Issues | p. 54 |
| Consumer Driven Health Plans: Contracting Implications | p. 55 |
| Consumer Driven Health Plans Overview | p. 55 |
| Payment Cards | p. 59 |
| Managed Care Contracting Implications | p. 59 |
| Coordination of Benefits | p. 59 |
| Stacked Deductibles for Out-of-Network Care | p. 60 |
| Timely/Prompt Pay Statutes May Be Difficult to Enforce | p. 60 |
| Probate Implications | p. 61 |
| No Preauthorization Required | p. 61 |
| Marketing Materials | p. 61 |
| Web Site Collaboration | p. 62 |
| Quality Assumptions | p. 62 |
| Most Favored Nations | p. 62 |
| Silent Preferred Provider Organizations (PPOs), Secondary Markets, and White Space Management: Three Terms That Translate to Revenue Erosion and Frustration | p. 63 |
| Secondary Discount Markets | p. 64 |
| How to Work around Them | p. 66 |
| White Space Management | p. 67 |
| Model Language Example | p. 74 |
| Single-Case and Continuous-Discount Arrangements | p. 77 |
| Quality Issues in Managed Care (Pay for Performance) | p. 81 |
| P4P Contract Terms and Conditions | p. 84 |
| Best Practices in P4P Contract Disclosures and Terms | p. 88 |
| Stating Program Objectives | p. 90 |
| Reimbursement Methods in Managed Care | p. 91 |
| Capitation | p. 92 |
| Capitation Demographics Analysis | p. 92 |
| Services | p. 93 |
| Dealing with Unpredictable and Unmanageable Risk Reinsurance | p. 93 |
| Dividing the "Pie" | p. 95 |
| Fee Schedules | p. 98 |
| Case Rates | p. 99 |
| Strategic Planning for Renewals and New Contracts: Understanding the Changing Competitive Environment | p. 107 |
| Begin at the Beginning: Define the Task | p. 110 |
| Who Are Your Competitors? | p. 111 |
| Forces That Influence Leverage and Competition | p. 112 |
| Step-by-Step Formulation of Your Competitive Strategy | p. 114 |
| Response to Competitor Actions | p. 115 |
| Preemptive Response Questions | p. 116 |
| Market Segmentation | p. 117 |
| Pricing | p. 118 |
| Promotion | p. 118 |
| Products and Services | p. 118 |
| Distribution and Logistics | p. 118 |
| Positioning | p. 118 |
| Signaling to Your Competition | p. 120 |
| Developing Alternative Strategies | p. 121 |
| Developing Business Rules for Better Contracts | p. 125 |
| Precontracting Due Diligence | p. 126 |
| Model Contracting Policy for Hospitals | p. 131 |
| Negotiation Techniques, Tactics, and Strategies | p. 137 |
| Contract Law Basics | p. 143 |
| Incorporation of Exhibits or Attachments | p. 145 |
| Specified Services | p. 145 |
| Standards of Care | p. 145 |
| Exclusion of Other Statements | p. 145 |
| Contract of Record | p. 146 |
| Express or Implied Contracts | p. 146 |
| Quasi-Contracts | p. 146 |
| Definiteness | p. 147 |
| Termination of an Offer | p. 150 |
| Duress Issues | p. 150 |
| Interpretation of Contracts | p. 150 |
| Unspecified Terms of an Agreement | p. 151 |
| Assignments | p. 152 |
| Delegation of Duties | p. 152 |
| Discharge of Contract | p. 153 |
| Bankruptcy | p. 154 |
| Breach of Contract | p. 155 |
| Liquidated Damages | p. 156 |
| A Checklist for Managed Care Agreements | p. 156 |
| Evaluating a Managed Care Agreement-Step-by-Step | p. 163 |
| A Checklist to Guide You | p. 163 |
| Preliminary Questions | p. 166 |
| Complete Contract | p. 167 |
| Identification of the Parties | p. 168 |
| Fact-Finding | p. 169 |
| Type of Plans Covered by the Contract | p. 172 |
| Utilization Management Program | p. 173 |
| Authorizations | p. 177 |
| Billing and Reimbursement | p. 179 |
| Quality Management | p. 185 |
| Term, Termination, and Contract Renewals | p. 188 |
| Miscellaneous Provisions | p. 191 |
| Organize Your Thoughts | p. 193 |
| Next Steps | p. 194 |
| Notes | p. 196 |
| Frequently Asked Questions | p. 197 |
| Appendix: Insurance and Managed Care Glossary | p. 199 |
| Index | p. 317 |
| Table of Contents provided by Ingram. All Rights Reserved. |
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