Managed Care Contracting Services

Providers lose revenue because they do not have the time to track and analyze their Managed Care contracts.

Did you know…

Managed Care Insurance contract rates are generally negotiable…when was the last time you were considered for a rate increase?

Managed Care Contract Services

Contract Review and Payer Analysis

Contract Preparation & Strategy

Rate & Language Negotiations

New Contract Implementation & Monitoring

What is Managed Care Contracting?

Contracting is the second step in becoming an in-network provider with the insurance companies. A Managed Care Contract, like any other formal business agreement, should be clear, consistent, comprehensive, and concise. It should include the intent of both parties, their respective rights and responsibilities, and the requirements of both state and federal law.

Key Areas of a Contract:

  • Reimbursement Rates
  • Contract Terms
  • Auto-renewal each year?
  • Lines of Business
  • Claims Submission Timeline
  • Insurance Payment Timeline
  • Termination Requirements
  • State and Federal Laws
  • Exclusions
  • Communication
  • Inclusive of HEDIS or other Clinical Quality Programs

Things to look out for in Managed Care payer contracts:

CLAIM EDITS:

Claims adjustments and edits, including paying at lower levels known as “downcoding” is generally done by the plan using a rules-based software and NOT the medical records. You should contractually limit a payer’s ability to edit claims. In addition, the payer should notify the physician or facility of a claim adjustment or edit, explain the variances, and stipulate that the physician or facility has the right to appeal any payment not conforming to the payer’s published edits.

TAKE BACKS:

Never sign an agreement that allows for unlimited overpayment recovery. Also be aware of contracts that allow for processing errors to be corrected by withholding against future payments. This may also be referred to as an “offset”. The payer should notify the physician or facility, explain the variances and have an appeal process in place for the physician or facility.

FEE SCHEDULE:

For a Fee Schedule to be effective for your practice or facility, identify the frequency of all procedures you perform and compare the fee schedule amounts to your high volume procedures. Also, be sure to understand how you are getting paid. It could be a % of Medicare Allowable for a specific year or prevailing, a % of your billed charges, capitation, or a payer may utilize a proprietary fee schedule. Upon entering a contractual agreement with a payer and every year thereafter, you should have an updated fee schedule provided to you and conduct an analysis to ensure your understand the changes.

FILING LIMITS:

It is important to know how long you have to file a claim. Some managed care payers have filing limitations as short as 30 days from the date of service, which is challenging. Try to negotiate a more reasonable amount of time, such as 60 days or at the very least, add a clause to the agreement which allows for “special” circumstances such as loss of key staff or significant equipment failure. Also, be sure you know about appeal limitations for identifying claim-process errors and notifying the payer. If you don’t report the error in the filing limitation timeframe, you will likely be refused reprocessing of the claim.

Managed Care Contracting