by Wyn Staheli, Director of Content - innoviHealth
Aug 4th, 2014 - Reviewed/Updated Mar 5th
The following frequently asked questions (FAQs) are adapted from the American Pyschiatric Association (APA). It is relevant to all types of providers with questions about managed care.
Q: I am having a problem getting in the network of managed care company X. They have a contract with a major employer in the area, so it is important for me to be able to join this network. What should I do?
A: When applying for admission to this network, stress your unique skills in treating specific populations and your expertise and willingness to do partial hospitalizations or inpatient when required. Any other outstanding qualities of your practice, such as flexible hours, knowledge of different languages and cultures, and experiences with other MCOs (i.e., demonstrating that you are managed care savvy) should be emphasized too. If you are currently treating patients for this employer, have the patients write to the managed care company requesting your continued services. If you are refused, apply again when the network opens.
Q: What are the common elements to look for in a managed care contract?
A: Have a lawyer review the contract. Pay special attention to term and termination provisions, risk allocation and liability, insurance coverage and limits, hold harmless provisions, confidentiality provisions, compensation provisions, provider obligations, party’s covenants or the rights and responsibility of each party in maintaining the contract, utilization review requirements, etc.
Q: Should I sign a contract with the “hold harmless clause”?
A. Do not sign a contract with the “hold harmless clause” unless it is reviewed by a lawyer. It may adversely affect your malpractice insurance. You may report the problem to the local District Branch (DB) and have them negotiate a modification or elimination of the clause (some DBs have been successful in doing this), or report the problem to the APA so we can negotiate with the company on your behalf. You may also cross out and initial your elimination of the clause if the rest of the contract is satisfactory to you. Some companies may allow this. You could also join the Legal Consultation Plan for a nominal fee. For an additional annual fee, they will review a fixed number of contracts per year. Please call (202) 682-6000 for additional information on the services offered by the plan.
Q: Company “A” will only reimburse me for medication management and not psychotherapy. What should I do?
A: Most companies will allow you to negotiate coverage for psychotherapy and medication management if the case is complicated and needs follow-up by the same provider. If you have this policy in writing, please send it to the Office of Economic Affairs and Practice Management.
Q: What do managed care organizations look for when selecting a provider?
A: The following are important considerations for MCO selection and retainment of providers:
- The philosophy of the provider regarding: outcomes; best interest of the patient; and the managed care principles that the MCO values.
- Privileges at the hospitals under contract with the MCO.
- The quality and appropriateness of the care, relative to the diagnosis and acuity of the patients he/she treats, attest to the provider’s commitment to quality. Does the provider have any special expertise in treating specific segments of the population or special diagnostic groups? Does the provider have internal mechanisms to monitor and improve quality? Is he/she board certified or board eligible? Board certification and board eligibility are measures of medical excellence that both MCOs and employers understand.
- A completed application with the appropriate licensure.
- Appropriate malpractice insurance as required by the MCO and a positive malpractice history that is verifiable.
- Favorable geographic location.
- Cost-consciousness of the provider. Is the provider flexible to negotiate different reimbursement arrangements and treatment patterns?
About Wyn Staheli, Director of Content - innoviHealth
Wyn Staheli is the Director of Content Research for innovHealth. She has over 30 years of experience in the healthcare industry. With her degree in Management Information Systems (MIS), she has been a programmer for a large insurance carrier as well as a California hospital system. She is also the author and editor of many medical resource books and the founder of InstaCode Institute.
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