What To Consider
In A
Managed Care Contract
What To Consider In A
Managed Care Contract
This material was jointly developed by State Volunteer Mutual Insurance Company and the
Jefferson County Medical Society.
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State Volunteer Mutual Insurance Company
Medical Practice Services Department
PO Box 1065
Brentwood, TN 37024-1065
615-370-1999
800-342-2239
http://www.svmic.com
•
Jefferson County Medical Society
101 West Chestnut Street
Louisville, Kentucky 40202-1881
502-589-2001
http://www.jcmsdocs.org
•
We wish to acknowledge the use of Aspen Publishers, Inc.’s Medical Group Practice
Legal and Administrative Guide in the preparation of this study guide. The material is
used by permission of the publisher.
SUBJECTS
(Click on the arrows to guide you through the study.)
What Is A Contract
Preliminary Questions
Standard Contract Provisions
Nonstandard Contract Provision
Provider Duties Under Contract
Payment Obligations Under Contract
Index (Click on the blue “?” at any time to take you to the index.)
What is the Contract?
• Who are the parties?
• Why is the documentation necessary?
• Is there always a contract?
Who are the parties to the
contract?
• You – is the contract with the individual
physician or with the practice, group or entity?
• Them
– You need to know exactly who the contract represents
so that you can confirm financial solvency, ownership,
and likelihood of success in the marketplace.
– Can the described entity expand the domain to whom
you must supply services ?– for example, “X
Corporation as well as its subsidiary and affiliated
corporations and health benefit plans with whom it has
agreed to furnish administrative services.” Thus
running the risk of expanding your obligations to
unidentified parties far beyond your expectations.
Why is the documentation
necessary?
• The contract will designate certain
obligations for each party. Having this
delineated in clear language benefits all
parties in knowing their rights and
responsibilities.
• The contract will state the remedies for
disputes.
• The contract will state how the
obligations and responsibilities can be
terminated.
Is there always a contract?
Like everything else in life, there are always
exceptions, but there will almost always be
contract in place for the managed care
relationship between the provider and the MCO.
Preliminary Questions
• Is the Managed Care Organization
(MCO) financially stable?
• Is the MCO properly licensed?
• What is the complaint history against
the MCO?
Is the MCO Financially
Stable?
• Ask for and review the MCO’s financial statement to check
for any evidence of financial instability.
• A financially unstable MCO may delay in processing
claims, deny authorization for services or referrals to
specialists, and retrospectively deny coverage for
previously authorized or emergency services.
• Because you may be required to provide care to an MCO’s
enrollees until the expiration of the contract term (and for a
period thereafter under continuation-of-care provisions),
you must have as much information as possible about the
financial condition of the MCO before entering the
contract.
Is the MCO Properly
Licensed?
Check with the appropriate state regulatory agencies
to verify that the MCO is properly licensed and
determine whether a history of complaints against
the MCO exists.
What is the Complaint
History Against the MCO?
• Talk with other physicians and group managers to
determine whether:
– The MCO’s performance is consistent with expectations when
they entered the contract
– Payments are made on a timely basis
– The MCO has a history of unjustified claims denials
– Any major administrative or procedural problems that may
exist with the MCO
• Check with the state Department of Insurance about
complaints against the MCO.
• Check with the Better Business Bureau about complaints
against the MCO.
Standard Contract
Provisions
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Recitals
Representations and Warranties
Declarations
Relationship of the Parties
Recitals
• General statements describing who the parties of
the contract are and what the contract is
attempting to accomplish.
• Usually very general in nature.
• Becomes important when disputes arise over
either parties intentions.
• Often important in disputes surrounding whether
the MCO is contracting with the individual
physician or the practice as a whole. For
instance – the MCO may refuse to negotiate
certain disputes with the group administrator if
the contract is with an individual physician.
Representations and
Warranties
• These are assurances by each party they
are in fact who they represent themselves
to be.
• Representations and Warranties often
include:
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Corporate Status
Licenses
Compliance with Law
Access to Financial Statement
Prior Authorization
Corporate Status
• Each party should identify its
corporate status in the contract.
Nonprofits should indicate such.
• Notification of change in corporate
status to other party.
Licenses
• Indication of licensing authority
(State Insurance Commission,
Licensing Board, Federal
Government)
• Proof of license
• Notification of change of license
Compliance With Law
Agreement to comply with all
applicable federal, state, and local
laws and regulations
Access To Financial
Statements
Providers should have access to
payer’s financial statements to
determine financial viability.
Prior Authorization
• All prior authorization required by
federal, state, or local laws has been
obtained
• If the board of directors of the
organization requires agreements to
be authorized, that authorization
should be obtained
Declarations
In the declaration clauses of the managed
care contract, the MCO and the provider
resolve all the “what if” questions related to
the agreement between the parties.
–Force Majeure
–Choice of Law and Severability
–Assignment
–Amendments
–Notices
Force Majeure
• When events beyond the provider’s
control prevents them from any longer
providing services, a force majeure
clause relieves them of responsibility.
• The clause will usually distinguish
between events that are beyond the
provider’s control and that simply
disadvantage the provider (in which case
the provider would still be obligated to
perform under the terms of the contract).
Choice of Law and
Severability
• Identifies which state’s laws will be applied in
interpreting the contract
• The contract should be in the state in which the
physician practices medicine because:
– The MCO may choose a state with laws more
favorable to them
– Legal expenses are much greater if the
provider must bring or defend a legal action in
a distant state
• Severability clauses allows a contract to
continue if a court invalidates a portion of the
contract
Assignment
• Assignment is the delegation or transfer of rights
and/or obligations under a contract to another person
not originally party to the contract.
• Most managed care contracts prohibit providers from
assigning their rights under the contract.
• Most managed care contracts are silent with regard
to the MCO’s right to assign their obligations under
the contract. This opens the door for an MCO
transfer or delegate its rights and responsibilities to
another party.
• It is usually in the providers best interest to restrict
the both parties ability to assign rights or delegate
duties under the contract without the other party’s
prior consent.
Amendments
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Any changes to the managed care contract should be in writing and
only after agreement by both parties.
Most managed care contracts have provisions for the MCO to make
unilateral changes. They justify this by asserting that it would be
administratively impossible to obtain signatures from all members of
their provider panels for policy and procedure changes or changes in
state and federal laws.
Providers should try to negotiate for at least advance notice of
changes and for the right to comment on proposed changes.
Some contracts have provisions that the MCO will notify the provider
of possible changes that will go into effect unless the provider
objects. These can be very dangerous if the practice does not
respond appropriately. For instance the MCO could propose
changes to the fee schedule that would go into effect unless the
provider group objects.
Without protection from unilateral changes, the provider’s only
recourse will be to terminate the contract which for many reasons
might not be in the best interest of the practice.
Notices
• Notice requirement generally layout how
notices are to provided to parties and to
whom.
• Essential elements include:
– All notices be in writing
– Addresses of the MCO and the provider
– The effective date of receipt of notice
specified
– Accepted methods of delivery
• You should insure that the elements are
administratively feasible.
Relationship of the Parties
• There is a legal theory, respondeat superior, that
requires that the MCO would be liable for the
negligent acts of its employees. To assure that does
not come into play, most managed care contracts
contain provision stating that both the MCO and the
provider have an independent contracting
arrangement.
• Most contracts also include a clause stating that
nothing in the contract shall be construed to require
physicians to recommend any procedure or course of
treatment that physicians deem professionally
inappropriate. This is to protect the MCO from
charges of engaging in the practice of medicine and
from liability arising from the negligence of any of the
physicians.
Nonstandard Contract
Provisions
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Key Definitions
Assignment of Enrollees to Providers
Listing in Directory of Providers
Plans for Which Services Will Be Provided
Physician Accessibility
Restrictions on Physician Referrals
Primary Care Physicians as “Gatekeepers”
Requirements or Limits on Employment of Personnel
Exclusivity Provisions
Term Provisions
Suspension Provisions
Procedures for Imposing Corrective Action on Physicians
Termination Provisions
Insurance Provisions
Indemnification Provisions
Dispute Resolution and Arbitration Provisions
Key Definitions
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Covered Services
Member/Enrollee/Insured
Covered Enrollee
Medically Necessary
Emergency
Covered Services
• The contract should indicate either
in the body of the contract or in an
appendix the services the provider is
to provide
• The contract (particularly in a
capitation situation) should state
which services are excluded from
coverage
Member/Enrollee/Insured
These terms sometimes are used
sometimes used interchangeably within a
contract to refer to person to which the
provider is obligated to render care, but in
other contracts one or all of these could
apply to entirely separate groups.
Therefore, the contract should clearly
state to whom each of these terms apply.
Covered Enrollee
• The contract should should clearly
and narrowly define the enrollee
population
• It should indicate the demographic
characteristics of the population
• Limit the contract to those covered
under the contract and not include
enrollees in affiliated plans
Medically Necessary
• The term should have clearly defined
standards that will be applied when
determining whether services provided
fit within the definition.
• This term often determines whether or
not the provider will be paid for services
rendered.
• Ideally the MCO should not have the sole
authority to determine medically
necessity.
Emergency
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Managed care companies often will not pay for
services provided in an emergency room that
they do not consider an emergency. There
should be a clear definition within the contract
stating how these situations will be handled.
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In some instances contract obligations may be
modified or expanded by statutes. For instance,
there are several provision in Kentucky law that
require payment for emergency services
rendered.
Assignment of Enrollees to
Providers
• Can be done in two ways:
– Enrollee selects individual physicians on
their provider panel (usual method)
– MCO assigns enrollee to a physician
based on geographic region, physician
availability and cost to the MCO
• With either method, the provider should
negotiate for the MCO to use its best efforts
to see that they are selected
Listing In Directory Of
Providers
• It is important that the provider be listed
in the print and electronic provider
directories as quickly as possible
because this is the method by which the
patients will choose their physician.
• The provider should have preapproval of
the descriptions used in the provider
directory to insure accuracy and
completeness.
Plans For Which Services
Will Be Provided
• MCO usually offer several different
types of managed care products
(HMO, PPO, POS) so it is important
that the provider be sure which plan
the contract is for.
• The provider should insure that one
plan does not automatically obligate
them to participate in other plans
unless that is the provider’s wish.
Physician Accessibility
• The contract may require physician
availability based on:
– Office-hour availability
– Telephone availability
– Emergency services availability
– Appointment availability
• The contract may require that
physician obtain approval for changes
in office locations
Restrictions On Physician
Referrals
• MCO contracts frequently restrict the
selection of physicians or other providers
to whom a physician may refer patients.
• There are usually exceptions for patient
emergencies.
• Physicians should insure that they are
comfortable working with other providers
within the MCO network before executing
a contract.
Primary Care Physicians As
“Gatekeepers”
• A Gatekeeper typically is obligated to:
– Preauthorize or deny specialty care
– Authorize or deny elective care
– Use only participating specialists and ancillary
services
– Monitor, manage, and coordinate all the care
assigned to patients including other physicians
and ancillary care
• This can be a particularly onerous task under a
capitation arrangement
Specialists should insure that they can work with the
plan’s gatekeepers before entering into a contract
Requirements or Limits On
Employment of Personnel
• These contract provisions usually revolve
around the use of Nurse Practitioners and
Physician Assistants
• Depending on the circumstances the contract
may require that provider use NP or PA’s
wherever possible OR not allow their use. It
is important to understand the impact of
these mandates on the practice before
signing a contract.
• In a few circumstances the contract may limit
the number of other personnel within the
practice.
Exclusivity Provision
• Some contracts establish a physician or group
practice as the exclusive provider for a given
geographic region. These arrangements can give
rise to antitrust concerns where a practice has
substantial market power and uses it to the
disadvantage of payer and/or competitors.
• Some contracts state that the MCO will be the
exclusive payer in exchange for a certain patient
base. This is a classic situation of “putting all your
eggs in one basket” where the physician risks
having the MCO not being able to supply an
adequate patient base or experiencing financial
problems.
Term Provisions
• The “term of the contract” is the time for which it
is to be in effect.
• Many contracts have provisions for automatic
renewals if neither party exercises the right to
terminate.
• Contracts should have rights to terminate without
cause within a reasonably short notice period.
• Many contracts allow for unilateral adjustment of
fees by the MCO, therefore, it is important for the
provider to be able to easily opt out of the
contract if the new fees are unacceptable.
Suspension Provisions
These provisions allow the MCO to
take temporary punitive measures
against the provider for not fulfilling
some of the obligations under the
contract without fully terminating
the contract.
Procedures For Imposing
Corrective Action On Physicians
• As part of the their quality assurance, utilization
review or other performance standards under the
contract MCO’s may have the right to take corrective
actions against the physician such as restriction of
clinical privileges, changes in compensation
amounts or termination of contract
• The contract should have description of grounds for
corrective action such as quality problems, patient
dissatisfaction, inappropriate utilization or costly
practice style
• The contract should provide for due process
protections for the physician
• The contract should state who has the responsibility
for taking the action
Termination Provisions
• Without Cause – usually with 60 to 90-day
notices for both parties
• With Cause – grounds include:
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Material breach of contract with failure to cure
Insolvency
Dissolution, merger, or sale of assets
Suspension or revocation of license
Loss of malpractice insurance or hospital
privileges
– Exclusion from Medicare or Medicaid
Insurance Provisions
• Managed care contracts usually impose
certain insurance requirements on
providers.
• Physicians and their groups are usually
both required by the contract to be
responsible for professional and general
liability insurance coverage.
• Providers should insist that that the MCO
carry both these coverages as well.
Indemnification Provisions
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Indemnification clauses protect one party from actions of another.
In many managed care contracts the standard indemnification clauses
attempt to shift the burden of claims arising from the MCO’s conduct onto the
provider.
As a general rule, professional malpractice insurance does not cover
contractually assumed liabilities where the provider would not be directly
liable under some other theory of liability.
It is unfair to expect the physician to assume the legal responsibility for the
negligent acts or omissions of the MCO.
Physicians should never provide indemnity for affiliated physicians unless
they are actual members of the same group.
The physician should seek to have the MCO indemnification obligations
extend to utilization review activities performed by third parties.
Physicians should demand mutual indemnifications that makes each party
fully responsible for its own actions and inactions under the contract.
Physicians should always have the indemnification provision reviewed by
their own attorney and their liability carrier.
Dispute Resolution and
Arbitration Provisions
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All managed care plans have processes for appeals and dispute
resolution, but the details are usually in the provider manual rather than
the managed care contract. The contract should reference these
procedures.
Some of the items that should be outlined in the process are:
– How a mediator will be chosen
– What rules will govern the process
– Specific time frames within which the procedures will take place
Many contracts contain arbitration provisions. If structured properly
these are good provisions for both parties
Some of the items that should be consider in the arbitration clause are:
– That it is binding on both parties
– Physicians should not agree to arbitration of malpractice claims
without first checking with his/her insurance carrier
– The contract should specifically include the right of both parties to
conduct discovery in connection with any arbitration proceeding
Providers Duties Under
Contract
• Services To Be Provided
• Policies and Procedures
• Holding Enrollees Harmless or Balance-Billing
Prohibitions
• Collection of Co-Payments and Deductibles
• Nondiscrimination Requirements
• Gag Clauses
• Maintenance & Retention of Records and
Confidentiality
• Facility Inspections
• Continuation of Service After Termination Of
Contract
Services To Be Provided
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Physicians should insure that there are clear definitions for
covered services, covered enrollee, and medically necessary to
insure that responsibilities are clearly understood. These
definitions will affect reimbursements under the plan.
The contact may cover other responsibilities including:
– Responsibilities to refer or accept referrals of enrollees
– The days and hours that the physician agrees to be
available to provide services
– On-call arrangements
Standard of Care:
– The physician should not be held to a standard higher than
those of the community in which he/she practices
– Terms such as highest quality can cause physician
difficulty in liability situations
Policies and Procedures
• Quality Assurance and Utilization Review
Policies and Procedures
• Credentialing Standards Applied to Participating
Physicians
• Compliance With Other MCO Policies and
Procedures
• Procedures For Verification of Eligibility
• Claims Submission Procedures
• Claims Procedures Involving Coordination of
Benefits
• Enrollee Grievance Procedures
Quality Assurance and Utilization
Review Policies and Procedures
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Quality Assurance (QA) programs are put in place so that MCOs can
insure that the care their enrollees are receiving is of an acceptable
quality.
Utilization Review (UR) programs are designed to control costs through
assurance that services the MCOs enrollees are provided are medically
necessary and appropriate. UR may be prospective, concurrent, or
retrospective, but typically requires prior authorization for all or certain
services.
Depending on the terms of the contract, QA programs may be conducted
by either the MCO or the medical practice.
Often the requirements for QA activities are detailed in documents outside
the managed care contract, but they should be reviewed in conjunction
with executing a contract and attaching them to the contract.
Physicians should insure that the provisions for the administration of UR
activities are consistent from the managed care contract and UR policies.
QA and UR requirements can be costly and burdensome to providers and
should be considered carefully.
Credentialing Standards Applied
to Participating Physicians
• The contract will impose credentialing standards on
physicians
• Credentials to be verified include:
– Current and continuing qualifications to practice
medicine
– State licensure
– Specialty board certification
– Federal Drug Enforcement Administration
registration
– Staff privileges at local hospitals
– Sufficient malpractice insurance
• The National Practitioner Data Bank will most likely
be queried
Compliance With Other MCO
Policies and Procedures
• The contract along with its appendices,
attachments and addendums reference
other policies and procedures with which
the physician is expected to comply.
• It is important that there be provisions
for a period of time in which a physician
can “cure” any non-compliance that
he/she is notified of by the MCO.
Procedures For Verification of
Eligibility
• MCOs will not pay for services of
enrollees whose coverage is not in effect,
therefore, the provider is usually required
to verify eligibility.
• Verification can vary – membership cards,
listings, telephone or computer checks.
• It is imperative that the process not be
burdensome and that it is available
anytime the physician sees patients.
• There should be provisions for how to
handle emergency situations.
Claims Submission
Procedures
• All managed care contracts will contain provisions
for the process of submitting claims.
• Generally the contract will specify the time frame in
which a claim must be submitted – usually between
30 to 90 days.
• The contract will have penalties for late submission
of claims. These penalties can range from limited
financial payment reductions to denial of the claim.
Physicians should insure that there are provisions
for handling late submissions without penalty for
which there are valid reasons.
Claims Procedures Involving
Coordination of Benefits
• Most contracts will require in situations where
the MCO is the secondary payer, that the
physician first bill and collect from the primary
payer before submitting their claim.
• Delays in collecting from the primary payer
could cause delays in submitting this
secondary claim. Physicians should insure
that there are provisions that allow for the
submission of secondary claims past the
“normal” filing deadlines.
Enrollee Grievance Procedures
• MCOs will have some process for handling enrollees
grievances. The physician should insure that they
understand these policies and how they will be
administered.
• Too often the MCO unilaterally makes decisions about the
grievance and then can require providers to take actions
such as waiving fees or determining that it will not pay for
services.
• The physician should seek to be able to participate in the
grievance process where appropriate, realizing this can be
burdensome and time consuming.
• The physician should be able to receive deferred payments
if the grievance is not found in favor of the enrollee.
Holding Enrollees Harmless or
Balance-Billing Prohibitions
• Hold harmless clauses prohibit the
physician from billing enrollees for
covered services. In some contracts and
in some states this provision is in force
even if the MCO becomes insolvent.
• Balance-Billing clauses prohibit
physicians from billing for the balance of
the amount not paid by the MCO except
for deductibles and co-payments.
Collection of Co-Payments and
Deductibles
• Many managed care contracts require that the
provider collect deductibles and co-payments
• There must be an easy means to determine the
amount of co-pay due – usually on the
enrollees membership card
• There must be an efficient way to determine if
the patient is required to pay a deductible and
how much of the deductible is remaining to be
paid – usually by calling the MCO
Nondiscrimination
Requirements
• Many contracts state that the provider must
provide services in the same manner to its
MCO enrollees as it does to non-managed care
patients
• Many contracts forbid the provider from
discriminating against providers based on
race, color, gender, age, health status,
disability, religion or national origin
• The physician should seek the ability to deny
services to an enrollee on the same grounds as
services would be denied to any other patient
Gag Clauses
• Typically allow for termination of contract by
MCO if the provider takes any action or makes
any communications that undermine or could
undermine the confidence of enrollees in the
quality of care provided by the MCO
• Gag clauses may prevent physicians
disclosing to patients treatment options that
the plan does not offer or from discussing
referrals outside the plan
• Physicians should endeavor to have these
clauses removed from the contract
Maintenance & Retention of
Records and Confidentiality
• Contracts usually require providers to maintain
both medical and business records for specified
times.
• Usually the contract will allow the MCO to
inspect, review, make or obtain copies of medical,
financial, and administrative records.
Additionally, physicians may be required to
submit periodic reports with specific practice
data.
• The contract should require strict confidentiality
of patient and practice information by both MCO
and physician.
Facility Inspection
• Most contracts give the MCO the
right to inspect or audit the
practice’s facility and certain records
• The physician should have a clear
list of what is eligible to be inspected
and only after appropriate advance
notice
Continuation of Service After
Termination of Contract
• The contract will likely require the physician to
continue to furnish services until they are
completed or the MCO has made appropriate
provisions for another provider to assume
responsibility
• The physician’s medical/legal responsibilities to
not abandon the patient supersedes the contract
• The contract should specify how the physician is
to be compensated for rendering this extended
care after the contract is terminated
Payment Obligations Under
The Contract
• General Payment Considerations
• Fee-For-Service
• Capitation and Risk Sharing
Considerations
General Payment
Considerations
• Time and Manner of Payment – the contract should
provide for payments to be made to providers by the
MCO within a specified period of time. There should
be penalty to the MCO for late payments. Providers
should attempt to remove clauses in the contract that
allow MCOs to offset prior overpayments against
current payments.
• Most-Favored-Nation Provisions – this clause
requires providers to adjust their fees whenever they
contract to perform the same services with a
competing MCO at a lower reimbursement level.
Providers should attempt to remove these clauses
from the contract.
Fee For Service
• The MCO will pay pay the physician based on a fee
schedule for service rendered
• The fee schedule is usually based on:
– A percentage discount from the physician’s usual fees
or from a “usual and customary” table selected by the
MCO;
– A set schedule provided by the MCO, or;
– A percentage of the Medicare fee schedule (this could
be above 100% of the schedule or a discount from the
schedule)
• The contract may exclude payments for certain services
• The contract may require approval before payment of
certain services
Capitation and Risk Sharing
Considerations
• Minimum Enrollment Guarantee
• Maximum Enrollment Limit
• Proration of Capitation Fees for
Certain Enrollees
• Division of Responsibilities
• Risk-Pool Arrangements
• Carve-Out Provisions and Stop-Loss
Insurance
Minimum Enrollment
Guarantee
• In assuming the risk for providing care for a
patient population providers need to insure
that there is sufficient number of enrollees to
spread the cost in an actuarially sound
manner
• The capitation contract should not begin and
should end when there is not a sufficient
number of enrollees
• In some instance the contract will call for feefor-service payments in times when the
enrollee numbers are below a threshold
Maximum Enrollment Limit
• Physicians do not want to contract
to provide more services than they
are able
• Physicians do not want to limit their
ability to contract with other
managed care plans
• The contract can limit the number of
enrollees the physician will accept
Proration Of Capitation Fees
For Certain Enrollees
• If the plan allows for enrollees to enter
during a capitation period there should be
provisions for adjusting the payment to
the physician
• If enrollees are retroactively enrolled the
payments should be accordingly adjusted
• The physician should not be liable for
services already rendered by other
providers
Division of Responsibilities
• The contract should have a matrix
attached detailing the responsibilities of
all the parties for the delivery and
administration of care to the enrollees
• This matrix will help insure there is a
clear understanding and will cover all
areas including diagnostics, home health,
laboratory services, UR, QA,
prescriptions, durable medical
equipment, etc.
Risk-Pool Arrangements
• Risk-Pools are made up of a percentage
of the capitation payment that is withheld
to incentivize the efficient administration
of services. If certain cost saving goals
are met the fund will be distributed.
• These pools obviously reduce payments
to physicians unless the goals are met
and even then much care must given in
setting and monitoring these programs.
Carve-Out Provisions and
Stop-Loss Insurance
• Carve-Out provisions allow for additional
capitation payments or fee-for-service
payments to treat certain specified
conditions
• Stop-Loss Insurance pays when the
expenses to provide care to a patient exceed
a certain level. The physician practice must
purchase this insurance either from the MCO
or an insurance company
Index
(Click on the red “I” box to take you to the topic)
Amendments
Arbitration provisions
Assignment
Assignment of enrollees to providers
Balance-billing
Capitation
Capitation - proration
Carve-out provisions
Choice of law
Claims submission procedures
Complaint history
Compliance with law
Confidentiality
Continuation of service after contract
Contract provisions - nonstandard
Contract provisions - standard
Coordination of benefits
Co-payments
Corporate status
Corrective action
Covered services
Credentialing
Declarations
Deductibles
Definitions
Directory of providers
Dispute resolution
Eligibility
Emergency
Employees
Index
(Click on the red “I” box to take you to the topic)
Enrollee
Enrollee - Covered
Enrollment - maximum limit
Enrollment - minimum guarantee
Exclusivity provisions
Facility inspection
Fee for service
Financial stability
Financial statements
Force majeure
Gag clauses
Gatekeepers
Grievance procedures
Hold harmless clauses
Indemnification provisions
Insurance provisions
Insured
Liability insurance
Licenses
Licensing
Malpractice insurance
Medically necessary
Member
Nondiscrimination requirements
Notices
Parties to the contract
Payment - general considerations
Payment obligations
Physician accessibility
Physicians duties
Index
(Click on the red “I” box to take you to the topic)
Plans
Policies - MCO
Policies - provider
Prior authorization
Procedures - MCO
Procedures - provider
Professional liability insurance
Proration of capitation fees
Providers duties
Quality Assurance
Recitals
Record maintenance
Record retention
Referrals - restrictions
Relationship of the parties
Representations
Responsibilities
Risk Sharing
Risk-pool
Services to be provided
Severability
Stop-loss insurance
Suspension provisions
Term provisions
Termination provisions
Utilization Review
Warranties
What To Consider
In A
Managed Care Contract