Textbook of Urgent Care Management: Chapter 22, Health Plan Contracting

By Sybil Yeaman

The Textbook of Urgent Care Management is now offering individual chapters for sale. The full book, provides an expert business consulting guide to potential or existing urgent care clinic owners, managers & operators as well as investors. Learn how to more effectively run your immediate care or walk-in center as well as start incorporating urgent care services into your existing primary care practice. The chapters cover valuable information from industry experts on how to start, manage, and even sell your urgent care center.

Chapter 22 includes:

Preparation for Contracting
- Gather Information About the Health Plan, Payment Methods, and Reputation
- Be Familiar With the Various Payment Models
- Establish Center Objectives and Determine Leverage in the Marketplace

Contract Review and Establishing Action Points
- Affiliates
- Arbitration
- Capitation and Carve-Outs
- Clean Claims and Claims Provisions
- Covered Services
- Credentialing, Eligibility and Verification
- Evergreen and Renewal Provisions
- Indemnification and Mutual Liability
- Medically Necessity
- New Plans and Product Lines
- Policies, Procedures and Obligations
- Professional Liability Coverage
- Termination Without Cause
- Unilateral Modifications
- Negotiation

Contract Follow-up

• Language: English
• Publisher: BookBaby
• Release date: Mar 15, 2014
• ISBN: 9781940288567

Book preview

CHAPTER 22

Health Plan Contracting

Sybil Yeaman

from

CHAPTER 22

Health Plan Contracting

Sybil Yeaman

NEW CHALLENGES IN THE health-care industry are driving sweeping changes in the models of how medical care is provided. Government pressure to provide medical care to the uninsured, an aging population, and health plans aggressively seeking cost containment all profoundly affect urgent care contract negotiations and their reimbursement. Understanding contracting and developing a successful negotiation process are more critical now than ever before.

Successful negotiation of contracts requires urgent care owners to understand their costs for providing medical care, their medical marketplace, the provider relationship with the health plan, the population and competition in their geographic area, and contract language. The time taken up front to prepare for contracting with health plans will provide leverage to negotiate more advantageous provider agreements and more favorable reimbursement.

PREPARATION FOR CONTRACTING

Understand Utilization and Costs to Provide Medical Care

Gaining a clear understanding of utilization and knowing the average cost per patient for doing business are the first steps in preparation for contract negotiations. If your center has not already established an effective utilization review process by payer and procedure, as well as an understanding of the costs to provide care, then start now.

Understanding utilization and the costs to provide medical care helps you determine if health plan fee schedules or higher-risk reimbursement rates cover the true costs of doing business or if they are unacceptable. This gives you leverage when