Know Your Rights: Managed care contractual protections October 13, 2016 Managed Care Know Your Rights, Managed Care, Payor Contracting 0 CMA’s “Know Your Rights” series summarizes vital protections under state and federal law that physicians should be aware of in their dealings with payors. Thanks to legislation sponsored by the California Medical Association (CMA), all health plan contracts with physicians are required to be fair, reasonable and consistent with California law and regulations. Contractual clauses that are specifically prohibited cover the following: Claims filing deadlines that are inconsistent with the law (see "Unfair Payment Practice: Timely Filing Denials") Financial incentives to deny, reduce, limit or delay care Gag clauses Hold harmless/exculpatory clauses Clauses imposing undue financial risk Clauses allowing for unilateral amendments by health plans (see CMA's "Contract Amendments: An Action Guide for Physicians," and CMA On-Call document #7057, "Managed Care Contractual Protections") Clauses requiring physicians to comply with undisclosed quality improvement or utilization management programs (See CMA On-Call document #7001, "Disclosure by Managed Care Plans (and Their Contracting Medical Groups/IPAs") Clauses requiring submission of medical records that are not reasonably relevant for the adjudication of the claim (see "Unfair Payment Practice: Unreasonable Requests for Medical Records" and CMA On-Call document #4202, "Health Plan Access to Medical Records.") Physicians who believe their contracts violate any of these laws are urged to contact CMA's Center for Economic Services (CES) at (888) 501-4911 or economicservices@cmanet.org. CMA managed care contracting resources Payor contract negotiations can be difficult. The California Medical Association (CMA) offers a number of free resources and services to help members and their staff simplify the contract review, negotiation and renegotiation process. Contracting education and coaching: CES provides one-on-one education and coaching on confusing or problematic managed care contracting issues. Contact CMA's reimbursement help line at (888) 401-5911 or economicservices@cmanet.org. "Taking Charge: A step by step guide to evaluate and prepare for negotiations with managed care payors": This toolkit provides physicians and their office staff with practical tips and tools to assist with the negotiation, implementation and ongoing management of complex managed care contracts. The toolkit includes sample forms and letters that may be customized for each medical practice. "Contract Renegotiations: Making Your Business Case": When submitting a request to open up a contract renegotiation discussion, best practice is to present a “business case” as to why the payor wants to keep your practice in the network. This resource will help physicians present a thoughtful renegotiation request meant to avoid the quick “auto-reply” from the payor indicating that they are not in a position to renegotiate at this time. Health plan contract analyses: CMA provides objective analyses of several health plan participating provider contracts. While these analyses are not intended to be exhaustive, they are designed to draw a physician's attention to issues which may warrant further inquiry or clarification. "Contract Amendments: An Action Guide for Physicians": This guide is designed to help physicians understand their rights and options when a health plan notifies them of a material modification to a contract, manual, policy or procedure. Financial Impact Worksheet: It is important that physicians understand how a fee schedule can affect their practice's bottom line so they can make informed decisions about health plan participation before contracts are signed. CMA has developed a simple worksheet to help physicians analyze proposed fee schedules and assess the impact fee schedule changes may have on their practices based on commonly billed CPT codes. Payor profiles: CMA's payor profiles include information for each of the major payors in California, including important contact numbers, addresses, and links for quick reference for payor interactions. "Best Practices: A guide for improving the efficiency and quality of your practice": This toolkit offers a series of proven steps that solo and small group practices can take to improve many facets of their practice. Chapter IX, "Surviving Out of Network: One Physician's Experience," offers practical advice, including tips on developing an out-of-network strategic plan. CMA On-Call CMA's health law library, CMA On-Call, includes several documents that address managed care contracting, including but not limited to: #7057, "Managed Care Contractual Protections" #7051, "Contract Termination by Physicians and Continuity of Care Provisions" #7053, "Termination/Exclusion: Action Plan for Physicians" #7055, "Exclusivity Provisions and Membership Requirements in Contracts, Including Most-Favored-Nation Clauses" #7001, "Disclosure by Managed Care Plans (and Their Contracting Medical Groups/IPAs)" Contract analysis service CMA-contracted attorneys provide written reviews of physician contracts for physician members. Contracts are reviewed for compliance with California and federal law and to determine whether, from a business and practical perspective, the provisions of the contract are beneficial for the physician or group. CMA members receive a 20 percent discount on the attorney fees when using one of CMA's contracted attorneys. For more information on CMA's contract analysis service, see On-Call document #7076, "CMA Contract Analysis Service." Tip: Physicians do not have to accept substandard health plan contracts. You can and should negotiate your contracts. Comments are closed.
