1. Some contracting issues in the managed care are plan components such as member, subscriber, medical director, provider, payer, physician and hospital. Routine medical services and experimental and/or investigational services, “medically necessary” and “emergent or urgent” medical services, services that providers are expected to provide under the contract and services that providers are not expected under the contract. What I feel that can be done to bypass these contracting issues in managed care is by all in involved coming together and creating a contract that is agreed upon everyone and that it is set across the board for each state involved so everyone can be on the same page. It can also be bypassed if some of the rules and regulations can be taken out or less stricken, so all that are involved do not feel that they cannot perform or conduct care due to the contracting laws. Also, providers should be allowed to make the determination of what services should and should not be provided to the patient, because managed care companies do not know the members as wells as the providers who treat these members to be able to make those type of decisions. Instead of these managed care plans setting laws and regulations that are adequate to them because it is the best way in saving money, they really should involve and get feedback first from the members, providers and hospitals to come up with resources in creating better contracts. I think it will be more effective if done this way and won’t have much issues.Bottom of Form
2. Managed care contracts are agreements between a managed care organization (MCO) and a service provider. In order for providers to be in contract with an MCO they must agree to meet the conditions and terms of the contract offered. If the provider fails to meet the requirements they can be charged a penalty.Providers who are part of these contracts agree to accept the set payment from the MCO as full payment. An issue that can arise from this is “balance billing” the patient. This is when a provider bills the patient for the left over cost of their services. To avoid this, providers should thoroughly read their contracts prior to signing them. They should also make any adjustments to their contracts before agreeing to them.Another term that can be part of the contract is precertification and case management. This agreement means that providers or their offices will obtain precertification prior to certain services. A provider’s office will call the MCO and provide necessary information to see if the service will be covered and if the MCO deems it medically necessary. If a service is done without a precertification the provider can get a financial penalty. In order to avoid this kind of problem providers must always find out if precertification is required through the MCO and if so be sure to get that service covered first. With case management the MCO may require to see a patients record if they have been admitted in the hospital. The MCO may not want to pay for all of the days a patient was admitted so they will require a review of the patient chart. In order to make sure a hospital gets paid for all of the days a patient is there providers should always make sure they are keeping correct notes in a patients chart.