Analyzing & Negotiating Physician Managed Care Contracts

Updated for 2019, this Master Class workshop covers an overview of 21 current and evolving MCOs, language analysis and identification of over 150 terms and phrases that increase risk through ambiguity, and how they apply and increase risk in “All-Payer” and “All Product” agreements for the services by your newly-employed physicians.

Maria covers bundled pricing with hands-on exercises and teaches workshop participants how to develop and define bundled case rates and risk mitigation through clearly defined episodes of care, revenue management terms and KPIs.

Contract analysts learn how to effectively push back on troublesome terms related to refunds, chart audits, payment audits, and fee schedule interpretations, complexities of physician reimbursement, capitation, and other issues related to physician contracting and hospital-based physician employment for those new to physician contracting.

Physician integration and alignment is addressed for analysts contracting on behalf of IPAs, PHOs, ACOs and MSOs. A new section has been added this year on disintermediation (contracting directly with self-insured employers and labor unions rather than through HMOs and PPOs).

After This Seminar, You’ll Be Able To:

• Feel confident in your understanding of 21 different types of third-party contracted reimbursement arrangements, including how to handle reference based pricing requests
• Feel more confident about your negotiation skills, tactics and strategies: what to ask for, how to ask for it, and how to leverage brand strength and differentiation
• Review insurance, HMO, PPO, Medicare Advantage, Managed Medicaid, ERISA and Taft-Hartley plan contracts
• Maximize reimbursement and minimize medical necessity denials and administrative hassle factors that erode margins
• Review contracts faster and paperless through the use of the software application provided with course materials
• Recognize problematic contract terms that impact reimbursement and operations and how to revise and push back with language alternatives from a contract snippet library provided with course materials
• Reduce surprise one-off and continuous discount arrangements, Silent PPO exposures, plan bankruptcy clawbacks, and medical necessity denials
• Negotiate capitation, per diem, shared risk, and percentage of charges rates, and adapt your contracted reimbursement strategies according to the offer on the table

Tools and Takeaways

Checklists of contracting and negotiation principles, software application that layers on top of MS-Word®, alternative contract language library, USB drive with supplemental reading materials, a sample managed care contract to use for practice identifying and responding to troublesome contract terms and conditions.

Level:

Beginner/ Intermediate / Advanced in contracting but new to physician contracting nuance.

Class Delivery:

Live, Hands-on, Interactive, Role Play

Prerequisites:

General knowledge of healthcare reimbursement and contracting principles

Credits:

14 hours if you attend the entire program