Question

Interpret managed care contract agreements and gain familiarity with language and strategies used by providers and managed care organizations.

Comparative analysis of managed care contracts

Answer 1

MANAGED CARE CONTRACT AGREEMENTS AND GAIN FAMILIARITY WITH LANGUAGE:

1. Contracts between managed care organizations and health professionals and clinical providers are a critical part of the modern managed care system
2. It is a network service agreement which comprises the legal standards which will follow the ethical principles of network of health care professionals.
3. it is complex process for health care professionals to adopt the legal standards and confusing one to follow
4. It will simplify the process and responsibilities for the payment for covered benefits and extensive discretion for the treatment decision making.
5. It explains the agreement that gives a physician in both individual and group practice a tool that can be utilized in the managed care contracting process.
6. It provides accessibility about the full scope of coverage and network access available to enrollees under the master contract
7. To identify the discrepancies within the language of the contract
8. Make sure all terms and definitions are clear, precise and exact.
9. Get clear and complete instructions regarding the delivery of covered services?
10. Agreement should include the payer compensation during special circumstances like billing and coding
11. Agreement should state the medical office obligations which are mentioned clearly in state and federal laws.
12. Agreement should also include managed care organization obligations.
13. Confidentiality is the key role
14. Terms should be specific and clearly defined with a start date and a termination date.

Strategies to facilitate managed care:

1. Conduct onsite reviews and call center monitoring:
   1. Interviews with the observations of health plan
   2. Maintaining customer relation officer
2. Collect data on beneficiary and provider experience
   1. Qualitative and quantitative data
   2. Focused groups data collection
   3. Prospective members of the focus group
3. Analyze and respond to feedback
   1. Developing preemptive strategies for state oversight
   2. Obtaining direct feedback
   3. Developing centralized complaint center
4. Conduct ongoing outreach and education:
   1. Maintaining continuity of care

Comparative analysis:

1. A thorough analysis of managed care contracts includes contract terms, billing guidelines, payment agreements and other pertinent contract provisions.
2. Auditing past claims to determine the payments are being paid according to contract.
3. To make important decisions about modifying, renegotiating or terminating contracts.
4. Awareness of vagueness and special attention to covered services, emergency condition and medical necessity.
5. Some contracts do not clearly state or define what is considered by the payer a covered service and can be difficult to interpret.
6. It will clearly explain about the process and criteria for credentialing
7. It will provide quality improvement programs