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MEDICAL SERVICE AGREEMENTS WITH MANAGED CARE ORGANIZATIONS
This class examines the medical service agreement between physicians and MCO’s. This agreement governs what the MCO’s will and will not pay for, what services can be provided without question, what services require prior permission, and perhaps the process by which exceptions are made. This agreement has the formula that tells how much providers are going to get paid. This class distinguishes basic terms of provider agreements with managed care organizations and how these terms effect the provider. Also, this class analyzes various payment mechanisms and how these mechanisms effect the provider. In addition, this chapter examines specialty contracting.
Class 7 Topics: MEDICAL SERVICE AGREEMENTS WITH MANAGED CARE ORGANIZATIONS
I. TYPICAL MANAGED CARE ORGANIZATION’S STRUCTURE FOR CONTRACTING WITH PRIMARY CARE PHYSICIANS
IV. TERM AND TERMINATION PROVISIONS
V. UTILIZATION REVIEW AND QUALITY ASSURANCE
VIII. SPECIALTY SERVICE CONTRACTING
Key Objectives
1. Distinguish basic terms of provider agreements with managed care organizations and how they effect the provider.
2. Analyze various payment mechanisms and how they effect the provider.
3. Summarize specialty contracting.
Review
1. Explain the basic structure of a typical managed care organization’s contract with Primary Care Physicians.
See: Charles A. Brown and John B. Reiss, Ph.D., J.D., "HMO Contracting Strategies Protecting the Provider’s Interests," Healthcare Financial Management (April, 2000): 36 - 42. Wayne J. Miller, "Legal Considerations in Managed Care Contracting," Topics in Health Care Financing (Winter, 1993): pages 17 - 25.
2. Explain the advantages and disadvantages of withholding pools or bonus payments for efficient utilization as used in medical service agreements.
See: Rhonda W. Sides, CPA, "Cost Analysis Helps Evaluate Contract Profitability," Healthcare Financial Management (February, 2000): 63- 66. Alan H. Rosenstein, "Cost - Effective Health Care: Tools for Improvement," Health Care Management Review (Spring, 1994): 59. Patricia Lohman, "Optimizing Revenues Through Effective Contract Management," Healthcare Financial Management (September 1, 1999).
3. Explain four factors for success in specialty service contracts.
See: Jeffrey M. Alexander, J.D., "Managed Care Contracting for Specialists, 1999 HFM Resource Guide: 6 - 10. Christine L. Malcolm and Mayumi Fukui, "Specialty Service Contracting," Topics in Health Care Financing (Winter, 1993): 68 -75.