What to Expect When Contracting with MCOs
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1 What to Expect When Contracting with MCOs Julianna S. Gonen, JD, PhD April 9, 2010
2 Disclaimer This presentation has been prepared by the attorneys of Feldesman Tucker Leifer Fidell LLP. The opinions expressed in these materials are solely their views. The information herein is being presented with the understanding that the authors are not engaged in rendering legal or other professional services. If legal advice or other expert assistance is required, the services of a competent professional should be sought. 2
3 General Provisions Definitions (non-exhaustive) Clean claim Covered services Medical necessity Payor / plan sponsor Member / enrollee / beneficiary Affiliate Products Effective date 3
4 General Provisions Relationship of parties Independent contractors Which provider facilities included in contract Scope of agreement Supersedes other or prior agreements between the parties Entire agreement Exclude provider manuals, etc. Non-exclusive 4
5 General Provisions Amendment: mutual, written consent Could have different process for material v. non-material KEY: What is material? Use of parties names and marks Third party beneficiaries Dispute resolution Informal, then mediation, arbitration upon mutual agreement Allowed to seek injunctive relief in court Assignment and delegation: mutual 5
6 General Provisions Term and termination Initial term at least one year Automatic renewal unless 90 days notice prior to end of term Distinguish non-renewal and termination 90 days notice for termination without cause Material breach Opportunity to cure, then 30 days notice Clearly defined continuing care period 90 days or state law Applicability of contracted rates following termination Might also apply to plan/payor insolvency 6
7 General Provisions Liability insurance: coverage and indemnification should be mutual Severability Governing law HIPAA Business Associate Agreement Notices Form Individual and address 7
8 Confidentiality Payment rates Should be mutual General Provisions Force majeure Bankruptcy / insolvency Waiver of breach Must be in writing Not continuing 8
9 Provider Rights and Responsibilities Services to be provided Usually in attachment Licensure of provider s employed personnel Subcontracting Avoid requirement to enter into written contracts with sub-contractors that are in accordance with the terms of the overall agreement 9
10 Provider Rights and Responsibilities Licensure / accreditation / peer review Adhere to accreditation standards only if accredited Utilization review Get policies if part of contract Provider can bill patient for non-covered services No waiver of patient cost-sharing 10
11 Provider Rights and Responsibilities Non-compliant patient transfer Legal / Regulatory compliance Never events Private payors adopting and extending - CMS initiative Initial focus: hospitals 11
12 Provider Rights and Responsibilities EMERGING ISSUE: Solvency requirements Regulator scrutiny now extending to providers Manifesting in contracts Disclosure, reserve requirements, prequalification 12
13 Payment MCO Rights and Responsibilities Fee schedule Usually attachment - should be incorporated by reference Changes to fee schedule must be negotiated and agreed to by both parties Claim submission Submit within 180 days of DOS (60 days minimum) If not, may be ineligible for payment (not shall) Form of submission (paper v. electronic) 13
14 MCO Rights and Responsibilities Prompt pay Usually state prompt pay laws will govern; may negotiate for shorter period and/or different rate of interest State prompt pay statutes tend to only apply to insured business; can contract to include for self-funded plans Possible alternate penalty: payment at charges (instead of fixed interest rate) Who has COB responsibility Annual rate increase 14
15 MCO Rights and Responsibilities Overpayment recovery Notice to Provider within [180] days No offsets Disputes subject to general dispute resolution provision No affirmative obligation to notify of overpayments 15
16 MCO Rights and Responsibilities Payors Payors should be required to issue ID cards Get update of payors monthly (if leased network / silent PPO) ISSUE: Plans subcontracting, passing full risk to downstream entities or other networks No payor can pay less than rates contracted for Provider can terminate selective payors without terminating entire agreement Payor may not unilaterally de-select Provider 16
17 MCO Rights and Responsibilities Eligibility verification / authorization Plan may limit to what is within its power to verify Can help with successor liability provision Policy and procedure modifications and publications Web posting, newsletter, updated provider manual, then deemed incorporated into contract Steerage 17
18 MCO Rights and Responsibilities Access to information / audit rights Limit to services within scope of agreement Should not survive agreement by more than 6 months at most ISSUE: Retrospective audits and recovery Reaching back further Using claim sampling Unilateral recoupment Plan posting rankings of providers 18
19 Negotiating Form research team to gather information about the MCO (strategies, financial strength, and operational methods) and the marketplace Examine your own capabilities to succeed and requirements for success under managed care contracts Develop objectives for Contract Develop deal points for negotiation of Contract 19
20 Negotiating Determine the bottom line for withdrawal from negotiations of Contract Select negotiating team Compare Contract as offered against deal point list Identify Payor and Payor plans involved 20
21 Negotiating Identify Provider and Provider services involved Obtain and review copies of all documents to be incorporated into the Contract Prepare Provider-required revisions to Contract for presentation to Payor 21
22 Negotiating Review legal implications of Contract provisions to be negotiated (e.g., antitrust, fraud and abuse, insurance regulatory, etc.) Negotiate Contract consistent with objectives, deal points, and bottom line previously determined Draft and review final language to reflect the negotiated terms of the Contract 22
23 Risk-Based Payment Methods Discounted fee-for-service Per diem charges Per case rate / global fees Capitation Percentage of premium Risk pools Pay for performance Government risk-based programs 23
24 Summary Have clear goals for MCO relationship Standard MCO agreement is negotiable Have focused negotiation team, with input from throughout the organization Negotiation involves business as much as legal considerations Involve counsel 24
25 Julianna S. Gonen, JD, PhD Counsel Feldesman Tucker Leifer Fidell LLP 25
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