Love ‘em or hate ‘em, managed care contracts aren’t going anywhere anytime soon.
They’re the glue that holds the healthcare ecosystem together, but dealing with them can feel a little like removing an appendix.
They’re time-consuming, packed with jargon, and can be a legal minefield if you don’t know what you’re doing.
As a provider, how you navigate these complicated healthcare contracts can make or break your business. But fear not, we’re here to help.
We’ve put together a managed care contract guide written with healthcare pros in mind. So let’s cut through the legal mumbo jumbo and get down to what matters most: making it easy to track and follow through on managed care contracts.
A managed care contract is a legally binding agreement between a healthcare payer and a provider that outlines clear parameters for two essential elements: the compensation the provider will receive for their services and the standards of care they are expected to deliver.
Here is a list of terms often included in managed care contracts:
The purpose of managed care contracts is to control healthcare costs while ensuring quality healthcare delivery to patients.
Managed care contracts are integral in the healthcare system, but navigating them is no easy feat.
Let's take a closer look at who uses these contracts and how they benefit:
Managed care contracts can help you navigate the complexities of healthcare administration.
As a healthcare provider, understanding the types of managed care plans available is essential to ensure you are meeting the needs of your patients and your practice.
Here's a brief look at how these managed care plans impact healthcare providers:
| Plan Type | Description |
| Health Maintenance Organization (HMO) | Think of HMO plans like an "all-you-can-treat" buffet with a catch. You get a fixed payment per enrolled member, but you've got to stick within strict referral and service use boundaries. Efficiency is the name of the game here. |
| Preferred Provider Organization (PPO) | PPOs are a bit like an exclusive club. They contract with providers like you to create a network. The bonus for patients is flexibility - they can see providers outside of the network but at a higher cost. You get a larger patient base, but sometimes at a cut rate. |
| Point of Service (POS) | POS plans combine features from both HMO and PPO plans. Patients can decide to stick within a preferred network (like in a HMO), or seek services outside of it (akin to a PPO). As a provider, it means you get the potential for more patient traffic but will need to navigate the varying reimbursement rates depending on whether services are in-network or out-of-network. |
| Exclusive Provider Organization (EPO) | EPO plans keep it simple for members, they can only see network providers unless it's an emergency. For you, that means offering competitive rates and gearing up for higher patient volumes due to the limited network. |
| Consumer-Directed Health Plans (CDHPs) | CDHPs are the frugal cousin in the family, pairing high-deductible insurance with a health savings account. You need to be ready to tackle patient concerns about costs and be mindful of potential care delays or avoidance due to high out-of-pocket expenses. |
| Medicare Advantage Plans | Operating under these plans feels like balancing on a tightrope. Yes, they're provided by private companies but you've got to stick to Medicare's quality and reporting standards. Plus, each plan carries its own specific rules for costs, referrals, and authorizations. It might seem like a complex dance, but for your patients, it could mean more coverage and added benefits compared to traditional Medicare. |
Understanding managed care plans can help providers make informed decisions about which plans to participate in and how to provide quality care to their patients while also managing costs.
Entering into a managed care contract is important to ensure you can offer quality care to your patients.
These contracts include several key components that outline the terms and conditions of the healthcare services you will provide:
| Covered Services | List of medical services that get included in the contract and covered by the healthcare payer |
| Physician or Provider Responsibilities | The obligations and duties that physicians or providers are responsible for under the managed care contract, such as providing timely and appropriate medical care, maintaining accurate records, and complying with regulatory requirements |
| Provider Networks | The other providers within the network who will deliver services and how they were chosen |
| Payment Models | How much the payer will cover, and the reimbursement schedule of how and when it will be distributed to the provider |
| Utilization Management | How the healthcare provider ensures that payers are using medical services efficiently and effectively |
| Grievance and Appeal | The process for resolving disputes between the healthcare payer and provider |
| Termination Provisions | What could cause a contract termination, and what happens if a contract is terminated, including notice requirements and any penalties or fees |
Knowing what these terms and conditions mean — and what they should include — is essential in making good business decisions.
Entering or negotiating a managed care contract is a collaborative process between healthcare administrators and insurance providers. Both parties bring valuable input to the table with the common goal of providing efficient and high-quality healthcare.
Understanding and negotiating the contract's terms isn't 'us versus them' but rather about finding a mutually beneficial agreement.
Here are some key aspects to consider when entering or negotiating a managed care contract:
Knowing what to look out for can give your organization an edge and help ensure you and your patients are being taken care of.
To ensure successful managed care contracting, healthcare providers should follow these best practices:
Taking these steps can make a world of difference when entering or negotiating a managed care contract.
Healthcare contract management software can be valuable for providers looking to streamline their managed care contract processes and ensure compliance with contract terms.
Here are some ways contract management software can help providers with managed care contracts:
Are you tired of struggling to keep track of your managed care contracts? Want to improve the efficiency and accuracy of your contract management process?
Look no further than ContractSafe!
Our contract management software streamlines your work, improves collaboration, enhances compliance, and provides greater visibility into the status of your contracts.
See for yourself how ContractSafe can revolutionize managed care contracting.