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Most providers are paid for their services through managed care contracts with managed care organizations (MCOs). Although there has been movement toward paying providers through value-based options instead of on a fee-for-service basis, the basic contract between the provider and the MCO is the foundation of the business relationship between the two entities and should not be overlooked.

Almost all MCOs present providers with a template or standard document and focus the negotiations on the rates or on creative options for value-based compensation and quality measures. A provider should review and negotiate the basic contract because the basic contract terms in the MCO’s standard document are likely less favorable to the provider and the provider should be prepared to negotiate key provisions, the contract must accurately incorporate specific terms the provider negotiated in any prior contracts and the contract should accurately reflect the newly negotiated terms between the parties, including revised rates, value-based compensation, quality requirements, and other significant terms.

In this webinar, attorney Eric Boughman addresses key contract provisions and guidance on issues associated with those terms to assist providers in managed care contract negotiations.

In discussing the preliminary considerations before the negotiation process, we’ll talk over how the provider’s business team should meet with counsel to discuss contract goals and concerns.

Counsel should confirm if there is a current contract with the MCO and address any outstanding issues, timing considerations, and obtain the proposed template or form agreement from the MCO. They should review the template for any changes that are less favorable, negotiated terms from the current contract not included, and new provisions related to quality measures.  Monitoring the pace of negotiations against any firm end date is important, and if the current contract is unlikely to be successfully renegotiated, options such as extending the current contract or addressing transition issues for patients should be considered.

Attendees will learn how a standard and complete managed care contract typically includes provisions that outline key aspects of the agreement and services. This includes defined terms important to the contract, identification of the parties involved, the products the Managed Care Organization (MCO) will offer, the length of the contract term, termination rights and notice requirements, procedures for adding or removing providers and locations, rates and rate adjustments for products and services, MCO policies and procedures, timelines for filing “clean claims”, billing for non-covered services, provisions for provider change in ownership or change of control, the period for retroactive claim denials, timeframes for recouping over- and underpayments, and procedures for handling changes during the contract term, including quality metrics.

In addition to the unique provisions in a managed care contract, we’ll talk about the importance of reviewing the standard contract terms. These may include provisions related to amendments, dispute resolution, communication and notices, and confidentiality.  Counsel should ensure that any amendments to the contract require the provider’s prior written consent, and carefully review any proposed changes for compliance with legal or regulatory requirements. Dispute resolution methods, such as a joint operations committee, informal negotiations, or arbitration, should be considered and included in the contract. Communication and notice methods should be reviewed, including using certified mail or targeted email addresses. Confidentiality issues related to patient information, contract terms, and quality measures for providers under the contract should also be addressed to protect the provider’s interests.

We’ll also discuss how the COVID-19 pandemic has resulted in significant changes to managed care contracting, including expanded coverage for COVID-19 testing, increased use of telehealth, and other waivers or benefits. Providers need to assess how these changes have affected their services, operations, and reimbursement, and whether they were executed through amendments or existing contract provisions. When considering new agreements, providers should consider limiting COVID-19-related changes to written amendments. Providers should also plan for transitioning telehealth changes post-pandemic and review and potentially revise government and commercial program provisions.

From a Managed Care Contracts for government perspective, we’ll learn these contracts may have mandatory terms set by CMS regulations or manuals, innovative terms that may change regularly, and unique training requirements.

Eric will also discuss the importance for the provider, including the business team and legal counsel, to ensure coordination with the provider’s other departments including the compliance department, risk management department and other departments responsible for quality reporting and initiatives.

Finally, attendees will gain insight into Federal and State Laws affecting managed care contracting.