Negotiating with Managed Care Organizations

Checklist for Negotiating a Managed Care Contract Know your costs Know your capacity Define your competitive advantages Know your market & define it for each MCO Understand the requirements & standards of each MCO

Checklist for Negotiating a Managed Care Contract Formulate each contract in terms of definitive levels of service Maintain patient opinion data regarding the services your organization provides Learn the level of ethical commitment of each MCO with which you are negotiating

Checklist for Negotiating a Managed Care Contract Have factual data in hand at the time of your first meeting with the MCO Assure that your organization establishes the precedent(s) for subsequent negotiations

Questions to Improve Negotiating Strategy with MCOs Questions to Improve Negotiating Strategy with MCOs (keywords) Registered Board members - who & how elected B.M. specialties - references Employer groups - can we contact Number of counties in the state & # of states Share types of contracts MCO carry professional liability for providers Require providers carry professional liability insurance - how much Insurance products of MCO valid & legal

Questions to Improve Negotiating Strategy with MCOs Questions to Improve Negotiating Strategy with MCOs (keywords) UR/QA activities MCO litigation history MCO investigated Blank spaces in contracts - explain Termination Termination notice requirements Documents not reviewed but referenced in agreement Mutual hold harmless agreement Exclusive contracts

Questions to Improve Negotiating Strategy with MCOs Questions to Improve Negotiating Strategy with MCOs (keywords) Restrict referrals Unilateral amendment of contract Contract clauses & state law Individual physician agreements - even in groups Arbitration requirements & effect on professional liability coverage Termination impact on doctor-patient relationship Confidentiality proprietary information

Questions to Improve Negotiating Strategy with MCOs Questions to Improve Negotiating Strategy with MCOs (keywords) Cost effective & quality services Oral representations Limits on physician’s professional judgment Time limit claims submission Timing guarantee claims payment Interest payment & delayed reimbursement Verify eligibility Contract identification of non-covered services Patient liability for payment of non-covered services

Questions to Improve Negotiating Strategy with MCOs Questions to Improve Negotiating Strategy with MCOs (keywords) Use physician names on brochures Prior authorization Modify office procedures Provision of services after contract is terminated Change of fee schedule by MCO Substitute physician when away Unspecified medical policies Unilateral alteration of standards of care Qualifications referral physicians

Questions to Improve Negotiating Strategy with MCOs Questions to Improve Negotiating Strategy with MCOs (keywords) Exclusion of specific specialty services Gatekeeper Indemnification provisions - difference between hold harmless & indemnification provisions Contract interfere with sound judgment Assumption of liability for payments after patient terminates without notifying provider Contract renewed automatically Underwriters length of time with company Can practice limit participation of new members

Questions to Improve Negotiating Strategy with MCOs Questions to Improve Negotiating Strategy with MCOs (keywords) NCQA accreditation status Reinsurance provided for catastrophes - specific with aggregate

Negotiating Posture & Tactics

Negotiating Posture Be organized –Spokesperson Be confident –Being persuasive vs. first being persuaded Be prepared –Advance preparation –Rehearsal –Thinking on your feet

Negotiating Posture Be ambitious –Person with higher expectations wins Be determined –Must ask to get Be positive –Confidence shows –So does haughtiness & rudeness

Negotiating Posture Be cautious –Opponent may read same things you do Be courteous –No bad manners or personal attacks Be reasonable –Don’t be stubborn –Deadlocks come from 2 people disagreeing Mostly unnecessary

Negotiating Posture Don’t assume –Everything is open to negotiation Don’t annoy –Learn first names Don’t posture –Impressing others & showing off Don’t let down your guard –“Let’s have dinner”

Negotiating Posture Recognize & gracefully accept success when it comes to you

Negotiating Tactics Seize the initiative –Choose your issues of import –Host session if possible Choose break times Adjournment Location of lighting Home field advantage

Negotiating Tactics Emphasize common objectives –Open channels of communication Remember the need to save face –One upmanship Demonstrate unreasonableness of opponent’s position –No personal attacks

Negotiating Tactics Use questions & hypotheticals –Use to learn needs & sticking points of opposition Sometimes best to say nothing –Rely on controlled body language –Brevity is the soul of success Never interrupt –Basic courtesy –Opponent may give useful information

Negotiating Tactics Make notes –Gives you time to think Thoughtful timing –Wait for right moment to seize the initiative Issues you can concede –Go for “win-win” Reduce final agreement to writing –Memo of understanding

Managed Care Facts & Figures

Facts & Figures See overheads