1. MCO Contract Negotiations
Managed Care Summit
Spring 2018

2. Presented by: Heather Champion, M.Ed, LPC Jessica Ramirez, MBA
Director of Business Development, Spindletop Center
Jessica Ramirez, MBA
Network Manager, Tejas Health Management Association

3. https://groupthink. kinja

4. Things to consider before entering negotiations

5. Questions to Ask Who is the initiating party? Why are we contracting?
Center or Payor
Why are we contracting?
New business, payor, or service
What type of product or service?
Medicaid, CHIP, Commercial
IOP/PHP/EOUs
When do we want the contract executed?
Prioritize negotiations
Knowing who the initiating party is will help guide the negotiation process. If it is the payor it may be in the center’s favor as the payor may be in a bind. If so, could mean higher rates and better terms for the center.
Knowing the why will help better stage the negotiations. Is it a new payor to the SDA? Are we looking to possibly add a new service to an existing contract? Or are we looking to add new business such as taking on more commercial business.
Type of contract is important. Is it Medicaid, Commercial, CHIP, etc. Or is it based on services?
Tells us what information, restrictions, reimbursement structures we are working with and if we can and want to take on that type of business.
When – If initiated by the payor, if they are looking at a fast turnaround, this may work in the center’s favor.
If initiated by the center, how will the timeframe impact business needs.

6. Create Contract Committee
Primary Liaison
Clinical Team
Business Development
Senior Leadership
Business Operations
Finance Operations
IT Operations
Create Contract Committee
The diagram may not be all inclusive for your center. The overall idea is to have representation from all primary functional areas.

7. Do Your Homework Revenue Cycle Management Know the following
Claims billed
Claims denied
Payments received
Anticipated business
Current payor mix
Current “issues” with payor

8. Do Your Homework Cost Analysis Cost to render services
Salaries
Administrative Costs
Transportation, etc.
Chargemaster/Fee Schedule
Be sure all services are included
Current rates
Flexible for updates

9. Do Your Homework Get to know the payor Where they do business
Locally
Nationally
Products offered
Medicaid
Commercial
Narrow Networks

10. Do Your Homework Get to know the payor General Reputation
TDI Filings
HHSC Reporting
Rate/Reimbursement Offerings
Medicaid
Medicare
Other

11. You already have an existing contract, but…

12. Looking to Amend Know where you stand Current and future utilization
Administrative burdens by payor
Claims analysis
Claims TAT (Turnaround Time)
Current client/member figures
Overall relationship with payor

13. Looking to Amend Know what they are needing Access standards
Quality measures
Reporting requirements
Credentialing process and TAT
Care coordination
Targeted populations
Payors will sometimes reach out to providers to enter into various contracts such a pilot programs for a new service or specific populations such as those under SMI. Before entering into any contract with the payor, it is best to know what all will be required of them first. This will allow the center to enter negotiations with a solid understanding of administrative costs/burdens and overall cost of care.

14. Hopefully you have not reached this point…

15. Roll up your sleeves, it’s review time!

16. Begin Contract Reviews
Primary liaison should do initial review
Draft bullet points of key items
Distribute to Contract Committee
Collect reviews
Discuss with committee
Formulate response to payor

17. What to Look for Review each section
Identify where language can and cannot be amended
Ensure the contract type is clear
Facility v Group
Are multiple contracts needed
Ensure all product attachments are present

18. What to Look for Ensure rate exhibit is present
Review reimbursement structure
Verify all respective billable provider types are covered under rate exhibit
Ensure all requested services are listed
i.e. PHP/IOP

19. Key Items to Review Term notifications Binding Arbitration
Generally list at least 90 day notification. Recommend 60 day.
Binding Arbitration
Suggest alternative language
Deemer/Opt-in/Opt-out language
Require both party signatures

20. Key Items to Review Lessor-of language Rates offered
Hard-coded/Static
Per Diems
% of Medicaid/Medicare
Default reimbursement terms
Recovery notification
Evergreen language

21. Better communication leads to better results…

22. While Reviewing the Contract
Establish a solid rapport with the contract negotiator or payor representative
Be prepared to educate on role of Community Centers
Respond to inquiries promptly even if no update is available
Note their responsiveness to your inquiries

23. While Reviewing the Contract
Check their provider resources section on their website
Review provider manuals
Provider notification process
Prior Authorization process and requirements
Provider Directory
This can be done prior to entering negotiations but should also be done concurrent. Extensive prior auth requirements or lag in provider manual updates may justify higher reimbursements to offset the administrative burden on the center.

24. But wait, there’s more

25. Process Review Be aware contracting process is ongoing
Once negotiated and executed review process should be implemented
Audit claims, authorizations, appeals to determine if renegotiations warranted
This can be done prior to entering negotiations but should also be done concurrent. Extensive prior auth requirements or lag in provider manual updates may justify higher reimbursements to offset the administrative burden on the center.

26. Contract Life Cycle Contract Life Cycle Contract Request Auditing
Review
Negotiating
Execution
Monitoring
Auditing
Contract
Life
Cycle

28. Questions ?

29. Good relationships are
Remember…
Good relationships are 🔑