Managed care contracting can strike fear in the hearts of even the most seasoned medical practice manager. One bad contract term can haunt you for years, particularly when it affects the income you’re bringing in. Your best bet is to do some legwork before you sit down at the negotiating table.
Check these eight managed care contracting tips that can help you get the terms that will help your practice thrive.
1. Research the MCO First
Two of the most important things to check about a managed contracting organization (MCO) before you sign on the dotted line are:
- Whether the MCO is financially solvent
- Whether the MCO works with the hospitals where your providers have privileges
You also want to research what other practices have said about working with them, ease of reaching your rep when needed and other factors. But the two items above should be the first steps during your research period. If the MCO doesn’t meet your needs there, you may not have reason to keep researching.
2. Gather All Required Documents
As you’re filling out your MCO application or credentialing form, make sure you attach every document the MCO requires, such as board certification paperwork, diplomas, proof of malpractice insurance, professional licenses, DEA certificates, and a roster of covering physicians or partners.
3. Know Your Files and Records
You should always be aware of and up-to-date on your credentialing records and your National Practitioner Data Bank record, when applicable. The MCO will want information on this topic, and if you don’t have it at the ready, it could slow down the process or hurt your negotiating power.
4. Pinpoint Your Malpractice History
Be sure that if you answer “yes” to any questions regarding malpractice history that you attach an explanation of any malpractice incidents, including detailed explanations of any nuisance suits, settlements, or verdicts in your favor. If you don’t and the MCO finds out later, it could lead to a null and void contract or unsavory contract terms.
5. Apply Way Ahead of Time
Be aware that the credentialing process is bureaucratic and may require three to six months to complete for any managed care plan. Therefore, always apply well in advance of the date that you will need to be credentialed by the plan. Furthermore, if you are hiring a new physician into your practice, begin the credentialing process for that physician as early as possible.
6. Be Prepared for a Site Visit
The NCQA accredits managed care plans and requires inspection visits for a certain number of physician offices each year. NCQA representatives will review your charts and records looking for sign-offs on every visit, documentation of all services provided to patients, allergies being clearly stated on records, and that each member of the family that you treat in your practice has a separate chart. The representative may also ask to see your OSHA and CLIA handbooks, may interview staff to determine if they are friendly and cooperative, will look at your reception area and waiting room, will inspect your exam rooms, and may even look in your refrigerator to ensure that you are not storing urine specimens with food.
7. Question Every Rejection
Even though managed care contracting companies are very tight-lipped about their credentialing decisions, you should always try to obtain an explanation if a plan rejects you. Certain administrative appellant procedures within the plan, as well as legal recourse, may exist to rectify a rejection.
8. Always Monitor Contract Terms
Never assume that the managed care plan is honoring your contract. Whether through inadvertence or poor intent, plans often “shortchange” reimbursements to physicians. Therefore, you should always audit your explanation of benefits statements or compensation checks carefully.
There’s so much more to know about how to forge a managed care contract with the terms you need. Healthcare attorney Michael R. Lowe, Esq., will show you the way during his 60-minute online training, Managed Care Contracts: Proven Language to Get Paid More. Register today!
Check out our Contract Negotiations Playlist on YouTube for the latest expert advice, and subscribe to our YouTube channel for step-by-step guidance!
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