Naya Kehayes, managing principal and CEO of Eveia Health Consulting and Management, recommends hospitals and other providers ask payors these 10 questions regarding payment of managed care contracts during negotiations.
1. Is the payment method clearly defined? Are there per diems, diagnosis-related groups, California Relative Value Studies or Current Procedural Terminology?
2. Can the payment method be easily adjudicated?
3. Are there provisions for limiting provider risk, such as stop-loss provision or minimum payment thresholds (hospital only)?
4. Are there late payment penalty provisions? If yes, are they easy to administer?
5. Are billing requirements consistent with standard provider practice; that is, are there billing forms and procedures?
6. Do payment provisions include a most-favored-nation clause (hospital only)?
7. To what extent are payment provisions tied to utilization review requirements?
8. Are service categories properly defined for purposes of payment (for instance, diagnosis-related groups or ICD-9)?
9. Are time restrictions included for billing?
10. Are mechanisms included for expedited payment? If so, are they easy to use?
1. Is the payment method clearly defined? Are there per diems, diagnosis-related groups, California Relative Value Studies or Current Procedural Terminology?
2. Can the payment method be easily adjudicated?
3. Are there provisions for limiting provider risk, such as stop-loss provision or minimum payment thresholds (hospital only)?
4. Are there late payment penalty provisions? If yes, are they easy to administer?
5. Are billing requirements consistent with standard provider practice; that is, are there billing forms and procedures?
6. Do payment provisions include a most-favored-nation clause (hospital only)?
7. To what extent are payment provisions tied to utilization review requirements?
8. Are service categories properly defined for purposes of payment (for instance, diagnosis-related groups or ICD-9)?
9. Are time restrictions included for billing?
10. Are mechanisms included for expedited payment? If so, are they easy to use?
More Articles on Managed Care Contracts:
New Hampshire Proposes 3 Managed Medicaid Contracts; Groups Call for Public Review
11 Managed Care Contract Questions Regarding Termination
5 Points on Managed Care Contracts