Benefits A Managed Care Contracting Lawyer Brings To You
Successful negotiation of managed care contracts is an integral part of business for physicians and physician group practices. The long-term success of a practice often hinges on the contractual provisions of a managed care contract, which affect payment, standard operating procedures, confidentiality practices, as well as clinical decision-making. Managed care contract lawyer, Barney Cohen of Concierge Healthcare Attorneys, helps physicians just like you throughout the United States. If Barney Cohen can help you, call him now for a free consultation at 312-804-1739 or send an email to: barney@conciergehealthcareattorneysllc.com
Avoiding Common Mistakes
To avoid common contracting mistakes, successful negotiation with a managed care organization (MCO) requires both thorough preparation and careful attention to the specific terms of the contract. Because of the magnitude of what is being undertaken, no managed care contract should ever be signed unless and until the contract has been carefully reviewed by an experienced managed care contracting lawyer.
Concierge Healthcare Attorneys, LLC has more than three decades of experience in healthcare law working directly with physicians. We act as your partner to review and successfully negotiate managed care contracts.
Best Practices For Physicians When Reviewing & Negotiating Managed Care Contracts
#1: Avoid Boilerplate Definitions
Boilerplate definitional provisions can raise serious issues and concerns. For example, precisely what the “covered services” encompass is critical since the physician will agree to deliver them, and perhaps, be financially responsible for them. The “covered services” should be listed explicitly in an exhibit to the contract.
#2: Insist On Clear Compensation Provisions
The managed care contract often does not clearly set forth the compensation to be paid to the physician for covered services. Managed care contracts often provide that reimbursement will be made pursuant to the MCO’s fee schedule “then in effect,” or pursuant to a fee schedule attached to the contract that lacks specificity. reimbursement. Separate schedules should be attached to the managed care contract identifying the exact compensation that is to be paid by the MCO for each covered service. This is a best practice area where the advice and counsel of an experienced managed care contracting lawyer can be incredibly beneficial.
The following reimbursement provisions should be included in a managed care contract to guarantee prompt and fair reimbursement:
- Uncomplicated procedures for efficiently obtaining from the MCO a binding advanced verification of a patient’s enrollment 24 hours a day, seven days a week, and 365 days of the year.
- Coding standards or requirements prohibiting bundling and/or down-coding by the MCO.
- Claim submission procedures and deadlines, together with a process for obtaining from the MCO a binding confirmation of claim receipt.
- A clear definition of a “clean claim” that places the burden on the MCO to timely return of any allegedly insufficient claim with a written description of the purported deficiency, as well as a clear statement that the MCO’s failure to return any purportedly deficient claim in a timely fashion will be deemed “clean claim.”
- A “prompt payment” provision specifying a certain number of days the MCO has after claim submission to make payment on clean claims, and providing a penalty for untimely payments.
- A “coordination of benefits” provision providing that MCO is obligated to make payments, unless the MCO can timely document that it is secondary.
- Subrogation Rights provision that binds the MCO to pay physician’s claims, notwithstanding the pursuit of subrogation rights against potentially responsible third parties.
#3: Look For Clarity That Medical Necessity Is A Physicians Discretion
Managed care contracts will limit reimbursement to “medically necessary” services, which can be subjective based on the person who defines “medically necessary.” Therefore, physicians need to ensure that “medically necessary” boils down to a clinical decision at the physician’s discretion and not the medical director or another person at the MCO.
#4: Ensure The Named Policies And Procedures Are Attached
Policies and procedures change over time, and a managing care contract needs to specify that amendments to them are not binding without the physician’s written consent. In addition, the current policies and procedures should be attached to the contract for review, creating the opportunity for a thorough analysis and preventing MCOs from holding physicians to policies and procedures that change unilaterally at will.
#5: Review Termination Terms
Contracts often are drafted by the MCO to allow for termination of a physician “for cause” (e.g., loss of licensure) or “without cause.” A physician must determine whether “termination without cause” is acceptable. In any event the physician should demand due process rights and a dispute resolution procedure. Our managed care contracting lawyer also recommend outlining that continuation of care post-termination will be paid for by the MCO should the physician be required to continue delivering care after the effective date of termination.
#6: Insist On Mutual Indemnification Provisions
The contract should contain mutual indemnification provisions requiring the physician and the MCO to each indemnify and “hold harmless” the other for liabilities arising as a result of their respective conduct.
Consult With A Lawyer To Discuss Your Managed Care Contracting
Enter your managed care contracting with confidence. Schedule your consultation with managed care contracting lawyer, Barney Cohen of Concierge Healthcare Attorneys, LLC online or call 312-804-1739 to discuss your managed care contracting needs.