The Managed Care Contracting Handbook, 2nd Edition: Planning & Negotiating the Managed Care Relationship PDF

Introduction

The most efficient approach to making your hospital or practice more financially responsible is just plugging the often invisible leaks that payers poke in your financial bottom line. Throughout this book you will learn tried-and-true tricks, tools, shortcuts, and techniques that you can use to evaluate current and future agreements with an eye toward clarifying and negotiating better contracts before they get the best of your hospital or practice.

Having trouble with Employee Retirement Income Security Act (ERISA) loopholes? Are silent preferred provider organizations (PPOs) eating up your revenue? Did you sign an evergreen contract without negotiating automatic capitation increases? Do you even know what these potential problems really mean? Identify and eliminate these and other contracting cancers by examining the hands-on advice found in these pages.

Managed care contracting is a complex process that can frustrate your best lawyers, hospital decision makers, and consultants. Know what questions to ask, terms to clarify, clauses to watch for and then make certain all that planning, clarification, and hard work is locked into the contract. (Trust me; it is not as easy as it sounds.) This handbook is an all-access guide to saving money by avoiding the pitfalls and reimbursement "gotchas" draining untold amounts of provider revenue each year.

This book is intended for decision makers such as chief financial officers (CFOs), revenue managers, contract analysts, business office managers, and hospital finance officers who have the daunting task of negotiating contracts for hospitals, medical groups, and physical therapy and other alternative site providers. Find facts and resources on everything from health maintenance organizations (HMOs) and PPOs to Consumer Driven Health Plans (CDHP), reimbursement methods, single and continuous discount agreements, self-funded ERISA payers, contract law basics, Medicaid managed care, and contract negotiating strategies.

Taken separately, these resources are an important dissection and discussion of managed care in its many complex forms. However, taken together, these chapters rise to the higher purpose of first decoding and then evaluating almost every reimbursement problem, loophole, and managed care contract agreement. With a fuller understanding of these practical components, this book's "Evaluating a Managed Care Agreement-Step-by-Step" (Chapter 15) is a detailed guide to examining and negotiating all future contracting. In addition, the "Insurance and Managed Care Glossary" (Appendix) is virtually its own guidebook/dictionary, explaining hundreds of acronyms, terms, and general managed care language.

The beauty of this book is that you can read it in any order you please. Skip to a section or chapter that holds particular interest to you or read it cover to cover. Start with those things affecting you directly, or gain a well-rounded understanding of managed care by examining all the unknowns that could affect your contracting and revenue. It is up to you. If there is an acronym or word you need clarified, just flip to the glossary. It is all here.

Whether you find yourself contracting for the first time or you are a veteran of many contracting wars, this book is an opportunity to gain an advantage over the often complicated language and uneven practices tipping the scale in the payer's direction. Do not let frustration and naivety guide important and binding contract decisions. Do not let your overburdened and often unprepared lawyer take on contracting challenges alone. Do not pay thousands of dollars for consulting when this contracting guide is as good (and a tenth of the price) of most fly-by-night consultants.

And if you do need more help, you are welcome to all the resources on my Web site, www.askmariatodd.com. Finally, if you still feel hopelessly lost, give me a call at 800-209-7263, and we can set up a complimentary 45-minute consultation that focuses specifically on your unique needs. Good luck and happy reading.