Individual Non Compete Contract by due15409


More Info
									Things to think about regarding contracts with Managed Care Companies (MCOs)
                          Two Levels of Contracting must be considered
                          The Contract between the Payer and the MCO
                          The Contract Between the MCO and the Provider or Network Member
      St-      MCO-
     MCO       Prov
      x         x         Accreditation standards
      x         x         Are risks/rewards reciprocal and symmetrical
      x         x         Assignability or subcontracting provisions
      x         x         At-risk for Court-ordered Treatment or other treatments ordered by public agencies
      x         x         Contract renewal options
      x         x         Contract termination (with or without cause); time period to give notice
      x         x         Coordination of Benefits; Billing other payer's first
      x         x         Guidelines or treatment criteria specific to children, adolescents, elderly
      x         x         Limits on referral of patients to providers in or out of the network
      x         x         Other dispute resolution mechanisms, arbitration, and remedies
      x         x         Responsibility for collection and retention of third party payments
      x         x         Responsibility to enroll members and to determine Eligibility
      x         x         Responsibility to maintain coordination with public agencies
      x         x         Retroactive terminations/additions to Eligibility files
      x         x         Scope of services and type of risks
      x         x         Term of the contract; time period and automatic rate increases, if any
                x         "Gag" clauses and other communications between patient and payers/plan managers
                x         At-risk provisions for continuing service to persons losing eligibility
                x         Balance billing and private pay allowances or prohibitions
                x         Collection and retention of copays and deductibles
                x         Competition/Non-compete agreements; Ability to assume MCO's functions and later
                  x       Denials; partial authorizations; grievances and appeals
                  x       Duty to accept all referrals
                  x       Exemptions for emergency care; definitions of emergencies; criteria for
                          "medical necessity"
                  x       Is contract specific to a defined group or general network provider agreements
                  x       Liability to continue treatment after Eligibility lapses
                  x       Limits on communicating other contract terms to others (e.g. fees being paid)
                  x       Malpractice insurance requirements and indemnification
                  x       Performance Bonuses or sanctions
                  x       Post contract termination responsibility for treatment continuity of care;
                          transfer of existing active clients
                  x       Provider Manuals as Contractual "Attachments"
                  x       Provider's or Plan's determination of medical necessity is binding?
                  x       Provisions for prompt payment (if FFS); Prompt PMPM payments
                  x       Requirement for individual staff privileging or coverage of all staff with
                          generic credentials
                  x       Reserves and bankruptcy
                  x       Rules for authorizations; self-referrals; gatekeeper rules
                  x       Separate contracts for commercial vs. public sector business
                  x       The cost of compliance (reports; authorizations; concurrent reviews, etc.)
                  x       The payer's commitment to volume and/or exclusivity
                  x       Treatment timelines
                  x       Use of treatment protocols; access standards; appointment timeliness
                  x       Withholds and their distribution; adjustments in withhold rates
                          Analyzing Contract's Impact
                            Legal Analysis
                            Actuarial Analysis
                            Business Plan Analysis: Cost of Compliance

       Pareto Solutions, LC                                   Page1 of 1             5374df05-f10c-44d6-9a8a-104974f9afa0.xls, Sheet1

To top