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ISMA Legal Department offers tips, questions to ask on contracting
Any time is a good time to educate yourself about your present and future contracts, including both their terms and reimbursement rates. With the current contracting period underway for the new Medicaid managed care organizations (MCOs), now is a great time for a review.
“Most of all, physicians need to remember that once they sign a contract, they are bound by it,” said Julie Reed, ISMA legal counsel. Here are some suggestions from Reed and the ISMA Legal Department:
- Carefully review your current agreements and note any important terms you want to appear/not appear in the next contract so you are more prepared when it comes time to re-negotiate.
- One critical feature of contracts is always who has a right to amend the terms of it and under what circumstances. For instance, if the MCO decides to amend the contract, is the MCO required to give the physician advance notice? Does the doctor then have a right to terminate the agreement if unhappy with the new terms? Do the amendment procedures apply to both the terms of the agreement and the fee schedule?
- Determine if you have a right to amend the agreement or propose amendments. In an ideal contract, each party would have the right to propose amendments, but no amendment would become effective unless both parties consented to it in writing.
- Understand your rights to terminate agreements. Can you terminate without cause, or only with cause? If only with cause, what constitutes "cause"? If you or the MCO terminate, how much notice must patients receive and who must send the notice?
- The new Medicaid MCO agreements will likely include a pay-for-performance provision. Study these carefully (See www.ismanet.org for a free educational session on pay for performance.)
- If you believe a contract has been violated, what are your rights and remedies as provided in the agreement?
- If you disagree with a claim determination, what appeal rights are available and what is the procedure for appealing? Is an external review available?
- Note the claims submittal deadline.
- Learn about procedures for determining if a patient is enrolled in a plan. Will it be quick and efficient?
- Discover what services/procedures require prior authorization, and how this will be obtained.
- Determine if all the fees in the fee schedule are above the office's costs (e.g., immunizations).
- Make sure you know how a "clean claim" is defined for purposes of paying under the prompt pay law.
- Does the MCO have a right to audit you? If so, how far back can they go? Note: Indiana aw limits the insurer's ability to go back to two years from the date of the overpayment, and requires the payer to give the provider notice of any overpayment before it can recover it from other payments.
The AMA has published its Fourth Edition, AMA Model Managed Care Contract (2005) and it is available to members and non-members free online here.
For a copy of “15 Questions to Ask Before Signing a Managed Care Contract” click here.
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