Transcript Slide 1

AMA’s National Managed Care
Contract and Database
Wes Cleveland, JD
American Medical Association
[email protected]
312.464.4503
Origin ─ Physician Perspective
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Many physicians continue to face take-itor leave it managed care contracts that
contain or lack terms not tolerated in
other industries.
Over two decades of managed care
regulations and laws, but ongoing
complaints regarding compliance.
The “regulatory addendum” approach not
entirely satisfactory.
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© 2012 American Medical Association. All rights reserved.
Origin ─ Insurer Perspective
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National health insurers complain about
the administrative burden they suffer
trying to comply with varying state
mandates.
Estimates at $400 million saved
annually.
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© 2012 American Medical Association. All rights reserved.
Process
• Challenge posed to national health
insurer ─ why not just develop a
nationally compliant contract?
• In response, one national insurer
represented that it would consider
such a contract if developed.
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Process
• Developed in coordination with
AMA/Federation workgroup
• Replaces the aspirational approach
adopted by the AMA’s Model
Managed Care Contract
• Based on statutes and regulations of
all states, DC, and federal.
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Structure-NMCC
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NMCC contains detailed
provisions/citations addressing issues
such as:
– disclosure of fee schedules and other
matters affecting payment;
– claims submission;
– claims processing;
– physician-patient communications;
– physician-patient advocacy;
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Structure-NMCC
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credentialing;
preauthorization and verification;
overpayments and underpayments;
dispute resolution;
amendment;
penalties for delayed claims
processing;
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Structure-NMCC
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all products clauses;
most favored nations clauses;
physician profiling and tiering;
secondary market activity; and
termination.
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Structure-database
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NMCC database fully searchable by topic,
word, statutory or regulatory citation,
state/federal, or AMA policy.
Searches retrieve NMCC text, full text of laws
and regulations, AMA policy, and/or issue
briefs on important managed care topics.
Text of NMCC and supporting database
continually updated to reflect current statutory
and regulatory requirements.
Access www.ama-assn.org/go/nationalcontract
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On-line community
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Join the new “Cutting-Edge Contracting Group”
online community
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Physicians, practice staff, and others who assist
physician practices will be able to discuss
contracting issues and share success stories with
respect to all practice contracting, not just managed
care contracting.
Sign up at
www.ama-assn.org/go/contractinggroup. Those
who sign up can receive a copy of the NMCC.
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Practice Management Alerts
www.ama-assn.org/go/pmalerts
Four steps:
– (1) Identify all of the services to be included in the
budget;
– (2) Predict accurately the extent to which your
expected patient population will utilize those
services. To do this, you will need the specific data
sets—level of transparency will be revealing.
Supplement with your own practice data: “Take
charge of your data: The physicians’ guide to
reviewing and using claims data to improve their
profiles, practices and payment.” www.amaassn.org/go/physiciandata
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© 2012 American Medical Association. All rights reserved.
Sign up for Practice Management
Alerts
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New toolkits, resources and webinars, e.g.,
managed care contracting, administrative
simplification, profiling, emerging payment and
delivery models
Unfair payer practices and how to effectively
address them
Tailored to each physician practice’s needs
Free of charge
www.ama-assn.org/go/pmalerts
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© 2012 American Medical Association. All rights reserved.
Additional Public Resources
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“ACOs, CO-OPs and other options: A
‘how to’ manual for physicians navigating
a post-health care reform world”
– Introduction: “Complex environment-difficult
choices;”
– Chapter 1: “Accountable care
organizations—overview;”
– Chapter 2: “Accountable care organization
governance issues”
– Chapter 3: “Partnering with hospitals to
create an accountable care organization;”
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© 2012 American Medical Association. All rights reserved.
Additional Public Resources
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Chapter 4: “Partnering with health insurers to create
an accountable care organization;”
Chapter 5: “CO-OPs and accountable care”
Chapter 6: “Guidance on earning electronic health
records incentive payments;”
Chapter 7: “Managing antitrust risk associated with
accountable care organizations”
Chapter 8: “Hospital physician employment
agreements”
Chapter 9: “Retaining independence while
embracing accountability: Care coordination and
integration strategies for small physician practices”
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© 2012 American Medical Association. All rights reserved.
Additional Public Resources
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“Evaluating and Negotiating Emerging
Payment Options”
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Introduction: “Evaluating and negotiating emerging
payment options;”
Chapter 1: “How to establish your baseline costs;”
Chapter 2: “Fee-for-service issues”
Chapter 3: “Pay-for-performance programs”
Chapter 4: “Capitation;”
Chapter 5: “Shared savings proposals;”
Chapter 6: “Bundled payments:”
Chapter 7: “Withholds and risk pools”
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© 2012 American Medical Association. All rights reserved.
Additional Public Resources
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Chapter 8: “Risk adjustment”
Chapter 9: “Stop-loss insurance”
Chapter 10: “Working with actuaries”
Chapter 11: “Negotiating the deal”
Chapter 12: “Joint contracting/Collective bargaining”
Chapter 13: “Ethical implications of financial
incentives in managed care contracts”
Chapter 14: “Evolving compensation methodologies
for employed physicians in an era of changing
clinical practice, reimbursement, and health reform”
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Additional Public Resources
www.ama-assn.org/go/aco
www.ama-assn.org/go/payment
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© 2012 American Medical Association. All rights reserved.