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1 Medicaid Managed Care Contracting Workshop Series for New York State Behavioral Health Agencies Workshop Office Hour Presented by: Adam Falcone, JD, MPH, Feldesman Tucker Leifer Fidell LLP Dan Ferris, MPA, NYU McSilver Institute, MCTAC 1
2 Workshop Outline Anatomy of a Contract & Team-Based Assignment (6/17) Participants review assignment and sample contract Send questions to MCTAC.info@nyu.edu with subject line Contracting Workshop Assignment ahead of Office Hour: July 8, 12:30 1:30 PM Participants finish assignment and submit responses using qualtrics survey link by 5 pm on Monday, July 20th. Wrap-Up with Assignment Review: July 29th, 9:30 AM MCTAC suggests: reviewing slides/recordings of kickoff series and Adam s initial training 2
3 Prior Contracting Trainings In-person contracting sessions November 14: Rochester November 14: Rochester November 25: Long Island December 9: Manhattan December 10: Albany January 13: Manhattan Web-based offerings: December 17: Managed Care Contracting: The Plan Perspective, featuring Harold Iselin and Whitney Phelps of Greenberg Traurig February 10: Contracting Overview and Office Hours with Adam Falcone March 25: Managed Care Contracting: The Provider Perspective, featuring Ron Lampert and Mark Furlong, Thresholds June 17: Anatomy of a Contract and Workshop Introduction feat. Adam Falcone 3
4 About the Presenter Adam J. Falcone, Partner -- Feldesman, Tucker, Leifer, Fidell A partner in the health law practice group, Adam counsels clients on a wide range of health law issues, with a focus on fraud and abuse, reimbursement and payment, and antitrust and competition matters. Drawing on his extensive knowledge of health care policy and markets, Adam regularly speaks to groups across the country on managed care contracting, value-based payment methodologies, and health reform opportunities. In particular, he brings strategic counsel to clients that are responding to changes in their local marketplace, negotiating participating provider agreements, and seeking to establish provider networks such as Accountable Care Organizations.
5 DISCLAIMER: EDUCATIONAL ONLY This training is provided for general informational and educational purposes only and does not constitute legal advice or opinions. The information is not intended to create, and the receipt does not constitute, an attorney-client relationship between trainer and participant. For legal advice, you should consult an attorney Feldesman Tucker Leifer Fidell LLP. All rights reserved. 5
6 FOUR PARTS OF THE CONTRACT 1. Header / Recitals Back Story 2. Contract Provisions Meat and Potatoes 3. Exhibits Moving Pieces 4. Referenced Documents Hidden Terms 2014 Feldesman Tucker Leifer Fidell LLP. All rights reserved. 6
7 EVALUATION PHASE A strategy is simply a plan of action for accomplishing an objective Feldesman Tucker Leifer Fidell LLP. All rights reserved. 7
8 EVALUATING THE CONTRACT 1. Consider timeframe for review 2. Assemble your contract review team 3. Assemble documents 4. Assess the MCO s Operational Performance 5. Assess the MCO s Financial Stability 2015 Feldesman Tucker Leifer Fidell LLP. All rights reserved. 8
9 EVALUATING THE CONTRACT Review the Contract Do you understand what all provisions mean? What provisions disadvantage your organization from a financial, clinical, operational, or legal perspective? Are responsibilities for each party clearly stated and all terms defined? Does the contract include all of the relevant appendices and exhibits? Have you reviewed any policies, procedures and documents referenced in the contract? Have you reviewed any references to statutes, codes, regulations to know what they say? Is the contract consistent with all other applicable Federal and State legal requirements? Does the contract reflects sound business judgment? (See Appendix A of these slides!) 2015 Feldesman Tucker Leifer Fidell LLP. All rights reserved. 9
10 EVALUATING THE CONTRACT Identify and Prioritize Issues Make a list of the issues you identified during the contract review process. Categorize each issue as follows: Red: Critical issues that without addressing you cannot afford to proceed because the risks (not just financial) are unacceptable for the organization Yellow: Significant issues that should be addressed before proceeding because they create undesirable risks for the organization Green: Issues that ideally would be addressed prior to proceeding to reduce potential risks 2015 Feldesman Tucker Leifer Fidell LLP. All rights reserved. 10
11 CONTRACT REVIEW Scope of Services. Does the contract cover the full range of services you provide, or at least those you wish to provide? Covered Services. Does the contract place any unreasonable limits on how you may provide services? Timely Claims. Does the contract make the MCO s denial of late claims discretionary rather than mandatory? Prompt Payment. Does the contract set forth a prompt payment provision that reflects New York s Prompt Payment Law? Correction of Overpayments and Underpayments. Does the contract allow the MCO to offset overpayments only after you have been given notice of the alleged overpayment and an opportunity to appeal the overpayment determination? Is there a limit to how far back an MCO can correct overpayments (other than due to fraud)? Does the contract offer you a similar amount of time to correct underpayments? Dispute Resolution. Does the contract contain a streamlined process for claims/payment disputes? Does the contract provide a reasonable process for dispute resolution? Does the contract permit the provider to resort to more formal dispute resolution procedures without first exhausting the MCO s appeal process? 2015 Feldesman Tucker Leifer Fidell LLP. All rights reserved. 11
12 CONTRACT REVIEW Cost-Sharing. Does the contract permit the provider to waive or reduce patient costsharing based on a determination of financial need? Payment Terms. Do the payment terms comply the reimbursement minimums set forth in the NYS BH RFQ? Are the payment terms for other products sufficient to cover your costs and consistent with prevailing rates? All-Products. Does the contract permit the provider to decide which of the MCO s products to participate in both now and in the future? Is the provider notified in advance of a new product and rates and given the right to opt-out? Regulatory Penalties. Does the contract not include a provision allowing the MCO to allocate to the provider any portion of regulatory penalties imposed on it? Termination. Does the contract allow the breaching party to cure (fix) most breaches prior to termination? Does the contract permit the provider to terminate the contract for cause in the event of the MCO s insolvency, bankruptcy or receivership? Term. Is the length of the term of the contract reasonable? If the contract includes an evergreen provision, is the amount of notice given to each party to terminate the contract reasonable? Amendments. Does the contract prohibit the MCO from amending the contract without the provider s notice and assent? Does the contract permit the provider to propose amendments? 2015 Feldesman Tucker Leifer Fidell LLP. All rights reserved. 12
13 CONTRACT REVIEW Insurance. Does the contract require both parties to carry appropriate amounts of insurance coverage? Indemnification. Does the contract provide for mutual indemnification of any losses, claims or liabilities that result from each party s willful and negligent conduct? Access Standards. Are you able to meet the access standards set forth in the contract? Does the contract permit you to make best efforts to meet those standards? Notice. Does the notice provision identify one or more individuals by name and title for official notices under the contract? Licensure. Does the contract only require you to report to the MCO final action taken by a state licensing board against a clinician (and not merely an investigation by a state licensing board)? Does a clinician's loss of licensure only result in termination of that specific clinician and not trigger rights to terminate the entire contract? Credentialing. Are the credentialing requirements and procedures clearly described in the MCO s provider manual? If desired, does the contract permit the provider to enter a delegated credentialing agreement? Utilization Management. Does the MCO s provider manual specify all services that will be subject to UM (including prior authorization, concurrent review, and other forms of coverage determinations)? Does the provider manual set forth the applicable standards of review? 2015 Feldesman Tucker Leifer Fidell LLP. All rights reserved. 13
14 Contract Exercise Review Participants review assignment and sample contract, submit responses using qualtrics survey link by 5 pm on Monday, July 20: Register for: Wrap-Up with Assignment Review: July 29, 9:30 AM 5 Sections in Example Provider Services Agreement: 1) Definitions 2) Provider Obligations 3) Billing & Compensation 4) Term & Termination 5) General Provisions 14
15 CONTACT INFORMATION Adam J. Falcone, JD, MPH Feldesman Tucker Leifer Fidell LLP th Street, N.W., Suite 401 Washington, DC (202) Feldesman Tucker Leifer Fidell LLP. All rights reserved. 15
16 Questions? Visit to view past trainings, sign-up for upcoming events, and access resources. 16
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