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Checklist for Negotiating a Checklist for Negotiating a Managed Care ContractManaged Care Contract
Checklist for Negotiating a Checklist for Negotiating a Managed Care ContractManaged Care Contract
• Know your costs
• Know your capacity
• Define your competitive advantages
• Know your market & define it for each MCO
• Understand the requirements & standards of each MCO
Checklist for Negotiating a Checklist for Negotiating a Managed Care ContractManaged Care Contract
Checklist for Negotiating a Checklist for Negotiating a Managed Care ContractManaged Care Contract
• Formulate each contract in terms of definitive levels of service
• Maintain patient opinion data regarding the services your organization provides
• Learn the level of ethical commitment of each MCO with which you are negotiating
Checklist for Negotiating a Checklist for Negotiating a Managed Care ContractManaged Care Contract
Checklist for Negotiating a Checklist for Negotiating a Managed Care ContractManaged Care Contract
• Have factual data in hand at the time of your first meeting with the MCO
• Assure that your organization establishes the precedent(s) for subsequent negotiations
Questions to Improve Negotiating Questions to Improve Negotiating Strategy with MCOs Strategy with MCOs (keywords)
Questions to Improve Negotiating Questions to Improve Negotiating Strategy with MCOs Strategy with MCOs (keywords)
• Registered• Board members - who & how elected• B.M. specialties - references• Employer groups - can we contact• Number of counties in the state & # of states• Share types of contracts• MCO carry professional liability for providers• Require providers carry professional liability
insurance - how much• Insurance products of MCO valid & legal
Questions to Improve Negotiating Questions to Improve Negotiating Strategy with MCOs Strategy with MCOs (keywords)
Questions to Improve Negotiating Questions to Improve Negotiating Strategy with MCOs Strategy with MCOs (keywords)
• UR/QA activities• MCO litigation history• MCO investigated• Blank spaces in contracts - explain• Termination• Termination notice requirements• Documents not reviewed but referenced in
agreement• Mutual hold harmless agreement• Exclusive contracts
Questions to Improve Negotiating Questions to Improve Negotiating Strategy with MCOs Strategy with MCOs (keywords)
Questions to Improve Negotiating Questions to Improve Negotiating Strategy with MCOs Strategy with MCOs (keywords)
• Restrict referrals• Unilateral amendment of contract• Contract clauses & state law• Individual physician agreements - even in
groups• Arbitration requirements & effect on
professional liability coverage• Termination impact on doctor-patient
relationship• Confidentiality proprietary information
Questions to Improve Negotiating Questions to Improve Negotiating Strategy with MCOs Strategy with MCOs (keywords)
Questions to Improve Negotiating Questions to Improve Negotiating Strategy with MCOs Strategy with MCOs (keywords)
• Cost effective & quality services• Oral representations• Limits on physician’s professional judgment• Time limit claims submission• Timing guarantee claims payment• Interest payment & delayed reimbursement• Verify eligibility• Contract identification of non-covered services• Patient liability for payment of non-covered
services
Questions to Improve Negotiating Questions to Improve Negotiating Strategy with MCOs Strategy with MCOs (keywords)
Questions to Improve Negotiating Questions to Improve Negotiating Strategy with MCOs Strategy with MCOs (keywords)
• Use physician names on brochures• Prior authorization• Modify office procedures• Provision of services after contract is terminated• Change of fee schedule by MCO• Substitute physician when away• Unspecified medical policies• Unilateral alteration of standards of care• Qualifications referral physicians
Questions to Improve Negotiating Questions to Improve Negotiating Strategy with MCOs Strategy with MCOs (keywords)
Questions to Improve Negotiating Questions to Improve Negotiating Strategy with MCOs Strategy with MCOs (keywords)
• Exclusion of specific specialty services• Gatekeeper• Indemnification provisions - difference between
hold harmless & indemnification provisions• Contract interfere with sound judgment• Assumption of liability for payments after patient
terminates without notifying provider• Contract renewed automatically• Underwriters length of time with company• Can practice limit participation of new members
Questions to Improve Negotiating Questions to Improve Negotiating Strategy with MCOs Strategy with MCOs (keywords)
Questions to Improve Negotiating Questions to Improve Negotiating Strategy with MCOs Strategy with MCOs (keywords)
• NCQA accreditation status• Reinsurance provided for catastrophes - specific
with aggregate
Negotiating PostureNegotiating PostureNegotiating PostureNegotiating Posture
• Be organized–Spokesperson
• Be confident–Being persuasive vs. first being
persuaded
• Be prepared–Advance preparation
–Rehearsal
–Thinking on your feet
Negotiating PostureNegotiating PostureNegotiating PostureNegotiating Posture
• Be ambitious–Person with higher expectations wins
• Be determined–Must ask to get
• Be positive–Confidence shows
–So does haughtiness & rudeness
Negotiating PostureNegotiating PostureNegotiating PostureNegotiating Posture
• Be cautious–Opponent may read same things you do
• Be courteous–No bad manners or personal attacks
• Be reasonable–Don’t be stubborn
–Deadlocks come from 2 people disagreeing• Mostly unnecessary
Negotiating PostureNegotiating PostureNegotiating PostureNegotiating Posture
• Don’t assume–Everything is open to negotiation
• Don’t annoy–Learn first names
• Don’t posture– Impressing others & showing off
• Don’t let down your guard–“Let’s have dinner”
Negotiating PostureNegotiating PostureNegotiating PostureNegotiating Posture
• Recognize & gracefully accept success when it comes to you
Negotiating TacticsNegotiating TacticsNegotiating TacticsNegotiating Tactics
• Seize the initiative–Choose your issues of import
–Host session if possible• Choose break times • Adjournment• Location of lighting• Home field advantage
Negotiating TacticsNegotiating TacticsNegotiating TacticsNegotiating Tactics
• Emphasize common objectives–Open channels of communication
• Remember the need to save face–One upmanship
• Demonstrate unreasonableness of opponent’s position–No personal attacks
Negotiating TacticsNegotiating TacticsNegotiating TacticsNegotiating Tactics• Use questions & hypotheticals–Use to learn needs & sticking points of
opposition
• Sometimes best to say nothing–Rely on controlled body language
–Brevity is the soul of success
• Never interrupt–Basic courtesy
–Opponent may give useful information
Negotiating TacticsNegotiating TacticsNegotiating TacticsNegotiating Tactics
• Make notes–Gives you time to think
• Thoughtful timing–Wait for right moment to seize the
initiative
• Issues you can concede–Go for “win-win”
• Reduce final agreement to writing–Memo of understanding
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