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regulatory agency,” - could this include a very minor offense? Make sure sufficient time is established for contract review before your anniversary or renewal date. WATCH OUT FOR:(1) HOLD-HARMLESS CLAUSES. These clauses declare that the provider shall indemnify and hold the MCO and third parties harmless from any liabilities incurred as a result of professional services provided (or not provided) by the physician with respect to a covered subscriber. Many MCO contracts presented will contain this clause. WE SUGGEST YOU CROSS OUT AND INITIAL/DATE THIS CLAUSE. As a minimum you should negotiate a mutual hold-harmless clause.Minor contract changes can be made in pen and ink on the face of the contract by simply initialing and dating the change. Major changes or new language should be by AMENDMENT/ATTACHMENT/ADDENDUM to the contract and signed by both parties.(2) MOST FAVORED NATION CLAUSE (OR MOST FAVORABLE AGREEMENT CLAUSE). This clause requires the provider to charge the MCO the same discounted rate (i.e. the lowest contracted rate) negotiated with any other MCO. Thus, if you give one MCO a 20% annual discount you must give the MCOs the same discount). WE SUGGEST YOU CROSS IT OUT AND INITIAL/DATE.(3) ALL PRODUCTS CLAUSE. This clause makes you a network member for all plans and products the MCO writes (HMO, PPO, Point of service, etc., which creates reimbursement issues and termination problems). WE SUGGEST YOU CROSS IT OUT AND INITIAL/DATE. The best method is to have separate contracts for each plan you are going to participate in or have the contract identify only those plans you wish to participate in. Certain provisions are contrary to Florida law.(4) RECORDS ACCESS AND CONFIDENTIALITY CLAUSES - Be cautious of how much information you must provide the MCO about your practice and your patients (including MCO access to your records and consent and cost requirements for obtaining or auditing copies of patient records). Some contract language requires you to indemnify the MCO for any fines or penalties they get based on inaccurate or incomplete information they obtain from you and pass on to others. Some contracts give the MCO access to your records up to five years after your contract terminates. Often contracts say they can access your records “upon reasonable notice.”We suggest you define what reasonable is. It is crucial for you to understand what you are signing.(5) NON-COMPETITION CLAUSES and EXCLUSIVE CONTRACTS. Contract language may preclude you from participating in other plans. These clauses are very dependent on the location and environment of your practice, but they only protect the MCO and never serve the physician well. Several types are in violation of Florida law.(6) WHISTLE-BLOWER CLAUSES. These clauses require that you report other providers for inappropriate use of discount rates, non-participating providers rendering care and balance billing, etc. Because of recent cases, these clauses don’t appear often.OTHER CONSIDERATIONS:(1) MAKE SURE THE CONTRACT DOESN’T VIOLATE FLORIDA LAW. Section 641.315, Florida Statutes, addresses and defines many terms and conditions required in an HMO provider contract. Especially ensure the contract aligns with the prompt pay laws (see Sections 641.3155 and/or 627.6131 Florida Statutes), which includes timelines for claims, denials, payments, appeals, interest, etc. MCO contracts will often include balanced billing language so make sure it is in accordance with Florida law. Balanced billing is usually not allowed within HMO contracts; however, it is allowed for non-participating providers seeing PPO patients. Also for PPOs, copay and deductible language will usually be included. If the contract mentions a section of Florida Statutes, read it, and make sure it identifies the year since statutes have the potential to change annually.(2) WATCH FOR UTILIZATION REVIEW LANGUAGE. Some contracts will require providers to“fully comply with” the MCO’s utilization management program. Make sure you understand what that program is and if it will affect your reimbursement rates. The Florida legislature is establishing more requirements for MCOs to audit/police medical providers. It is also giving administrative agencies more authority to review and prosecute “utilization” violators (which are reported by the MCOs). Ensure adequate and agreeable appeal language is included. The legislature is also demanding increased use of practice parameters and guidelines by physicians; violations open new doors for medical liability suits.(3) MAKE SURE YOU UNDERSTAND THE MCO DISPUTE RESOLUTION PROCESS. As always, make sure you have adequate notice and have time to respond or provide required information. Is there an arbitration clause; is it final and binding? Where would arbitration be held (we suggest you make it in your county)? If you want the ability to arbitrate, make sure you understand all potential issues involving arbitration and ensure that parties share costs.(4) WATCH FOR REFERENCED BUT MISSING DOCUMENTS. MCO contracts will often reference other documents (i.e. an unfamiliar fee schedule, definitions, programs, etc.) that are incorporated into the contract, but not provided to the physician. Watch for “except as otherwise specified herein” language, or “as required by applicable law.” If you can’t find what they are referring to, ask to see/review copies or have the MCO point it out BEFORE you sign the contract.(5) DON’T LEAVE ANY BLANK OR OPEN SPACES. This will only lead to misunderstandings and disputes. As a minimum initial the space so you will remember that it was blank.(6) MAKE SURE YOU UNDERSTAND THE MCO’s REFERRAL POLICIES. Does the contract allow you to refer patients to specialists as you deem medically necessary?YOU CAN NEGOTIATE WITH MANAGED CARE ORGANIZATIONS Contracts are written by and for the benefit of the MCO, thus it becomes your responsibility to make the relationship work for you. While the ability to negotiate often depends on the number of providers in your locality – groups reduce the number of individual providers available and give bargaining power – you will never know your power to negotiate until you exercise it. Always think about and prepare offers and counter offers. Knowledge is power - contract negotiating power and the power to save/make money with MCO contracts. Be reasonable, go into the negotiation with a “win-win” philosophy, and use the negotiation exercise to open an honest dialog with the MCO. But also remember, “If it ain’t in writing, it ain’t agreed on.” Also do not get frustrated talking to MCO provider relations personnel. If they do not have the power to modify your contract, ask and get to the correct authority immediately.You can change the contract mailed to you. Look for potential additions or changes in contract language in sections dealing with the following: claims filing/payment deadlines if different from state law; how the MCO resolves disputes; amounts paid for primary, secondary, and tertiary procedures; the ability to drop patients/subscribers; contract termination policies; charging subscribers/members for non-covered services; refunds; contract revisions; carve-outs, etc. Always be alert for phrases that limit the liability of the MCO. An area that providers often overlook when reviewing an MCO contract is the MCO’s CPT code bundling and modifier methodology. MCOs have proprietary software programmed to accept only certain ways of bundling CPT codes and deny the claim if certain modifiers are used. There will be some variation between MCOs in their coding and bundling methodology and understanding each will reduce billing frustrations. One approach is to offer several combinations of oft-performed procedures (using CPT codes) that you use in your practice to the
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