Managed Care Contracting

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About Course

Format: Live Webinar
Presenter: Eric C. Boughman
Event Date: TBD
Time: 12 pm ET | 11 am CT | 10 am MT | 9 am PT
Duration: 60 minutes

Conference Materials (Password Required)
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.

Learning Objective:

  • Understanding preliminary considerations before the negotiation process
  • Identifying key managed care contract provisions.
  • Knowing standard terms affecting managed care contracts.
  • Knowing COVID-19 changes to managed care contracting.
  • Identifying contract terms specific to managed care contracts for government-covered services.
  • Understanding coordination with other departments post-contract implementation.
  • Identifying Federal and State laws affecting managed care contracting.

Areas Covered in the Session

  • Preliminary considerations before the negotiation process.
  • Key managed care contract provisions
  • Standard terms affecting managed care contracts.
  • COVID-19 changes to managed care contracting.
  • Managed care contracts for government-covered services.
  • Coordinating with other departments post-contract implementation.
  • Federal laws affecting managed care contracting.
  • State law issues affecting managed care contracting.
  • Live Q&A Session

Suggested Attendees

  • Legal counsel and other professional advisors to healthcare providers
  • Healthcare providers and staff
  • Hospital and healthcare facility administration
  • Vendors and contractors who work in the healthcare sector
  • Physician
  • Nurses
  • Physician Assistants
  • Healthcare Billing and Coding Staff
  • Credentialing and Enrollment Specialists
  • Healthcare Administrative Personnel
  • Clinic Managers
  • Credentialing and Enrollment Specialists
  • Healthcare Administrative Personnel
  • Practice Managers
  • Auditors
  • Compliance Officers
  • Medical record supervisors
  • Health Information Management Administrators and Technicians
  • Other Personnel Interested in Billing Privileges with the Medicare Program

About the Presenter

Eric Boughman is an AV-Rated Attorney and Certified Circuit Court Mediator whose law practice focuses on serving clients in the business of healthcare, technology, and other select industries. A diverse background that includes litigation, regulatory, and transactional matters has provided Eric with experience to solve complex legal issues with a focus on compliance, risk management, and avoiding or reducing exposure from legal threats and lawsuits.

Eric particularly enjoys helping clients avoid lawsuits or resolve them quickly through creative mediation and dispute-resolution techniques. The most rewarding components of his practice involve serving as a mediator and as general counsel with clients on a regular, long-term basis.

Eric is a frequent writer and presenter on issues involving healthcare law, technology, and asset protection. His writings have appeared in multiple American Bar Association publications, The Florida Bar Journal, Forbes, Daily Business Review, Accounting Today, Kiplinger, Financial Advisor Magazine, Law360, and CEO World, among others.

Eric is admitted to practice law in Florida and Nevada. He has appeared in other forums throughout the country, pro hac vice, or as counsel in alternative dispute resolution proceedings involving Medicare disputes and other healthcare payer audits.

Course Content

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