Managed Care

Managed Care Sample Contract Language Library

The following is a compilation of managed care contract language that I have collected over the last 20 years of contracting in managed care. It is a tool I use regularly in my own work. Please do not use this language without appropriate legal counsel, taking into account the individual situation or circumstances giving rise to the agreement. AskMariaTodd™ hereby authorizes you to view, store, print, reproduce, copy, and distribute any pages within this website for non-commercial use within your organization only. In consideration of this authorization, you agree that (a) any copy of these documents that you make shall retain all copyright and other proprietary notices contained herein and (b) this page is included with any distribution. The information contained herein is for informational purposes only as a service to the public, and is not legal advice or a substitute for legal counsel, nor does it constitute advertising or a solicitation. You may only use the service if you agree to these terms. If you do not agree, do not use the service. This contract limits our liability and disclaims warranties for the service to the maximum extent permitted by law.
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Signing or Initialing Each Page of a Contract?

In U.S. practice, signatories often initial pages adjacent to each place where the printed text has been altered in some way. Otherwise, the parties do not typically initial each page. However, it is required by statute in the case of some contracts. For example, Ohio Revised Code requires that each page of a contract providing for a non-recourse civil litigation advance must be initialed by the consumer. With business contracts in the U.S., it would be unusual for the parties to initial each page, but because much of the contract is now based on terms and conditions referenced in managed care agreements that reside on a website that can be changed very easily with a content management system, it wouldn't be difficult to understand why doing so would be far fetched. The purpose for doing so is to confirm that no pages or terms and conditions were added or subtracted.

How Medicare Advantage Plans Get Paid

To understand how the money flows in Medicare Managed Care, one must understand how the plan is funded. in the 1990s, Medicare + Choice plans were underfunded to such a degree that no attempt at negotiation would ever yield enough money for hospitals to sustain interest because the money simply wasn't available to pay them. It is concievable that the same could happen to a Medicare Advantage plan because there are so many plans available that one might find themselves contracted with a plan that does not have enough enrollment of helathy non-utilizers to receive adequate funding to cover expenses incurred by those with heavier utilization. If the reinsurance is inadequate, the plan could find itself in financial distress. This is one reason that I stress due diligence prior to contracting with new plans of any type.

Managed Care Process Improvement Worksheet

Here is a helpful Managed Care Process Improvement Worksheet. I use this form to pull together a task force to address a particular problem that requires a cross functional multidisciplinary team to resolve.

Your Ethical and Legal Obligations vs The Plan's Utilization Management Policies

Physicians retain the right, as well as ethical and legal obligation, to provide appropriate care whether or not treatment and/or payment is authorized or approved.

Understanding the Silent PPO Arrangement

Take Steps to Prohibit Uncontrolled Access to Your Discounted Rates

Many patients, physicians, hospitals and other providers are victimized by this practice that is outlawed in some states, but only if the provider does not take steps to strategically exclude

Avoid Medical Necessity Denials by Payors

Often, managed care contract boilerplate language requires providers to discount charges to patients who are members of a health plan that deems a particular procedure, service, drug or supply as "medically unnecessary". This allowance in negotiated terms causes hundreds of thousands of unpaid dollars to countless providers. The practice is widespread because the providers did not fully grasp the implications of one word in the draft provision.

Use Caution When Negotiating Provisions for a Health Plan's Inspection of Records

Most providers are familiar with this sort of language and have seen an "access to books, records and papers" provision in each of their contracts. However, this particular language has a few subtleties that can cause lots of problems with reimbursement,

Selective Termination of Payers

Many times healthcare providers are placed in a difficult position in their contracted reimbursement relationships.

Reimbursement for Copies of Medical and Other Records

No one will protect you if you choose to give away your rights. In most states, medical records copy fees are established in law or administrative code. Health Plans often include language in their draft agreements that entitles them to free copies of medical records.