OVERVIEW OF MEDICARE January 28, 2010
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Transcript OVERVIEW OF MEDICARE January 28, 2010
Managed Care Contracts: Drafting
Considerations for Providers
Negotiating Favorable Rates and Terms and
Anticipating Areas of Dispute
Thursday, March 8, 2012
Sarah E. Swank
Ober|Kaler
Alan J. Arville
Ober|Kaler
Dennis G. Hursh
Hursh & Hursh
202.326.5003
[email protected]
202.326.5020
[email protected]
717.930.0600
866.DOC.LAW1
pahealthlaw.com
Overview
Health Care Reform and Current Environment
Quality and Cost Containment
Technology
Government and Payor Enforcement
Key Contractual Provisions
Questions
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Introduction
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Introduction
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Introduction
Why is next year so important?
I will give you a hint:
It is happening on November 6, 2012.
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Current Environment
Move away from fee-for-services
Health Insurance Exchanges
Accountable Care Organizations
Cost and Quality Transparency and Reporting
Data Sharing
Any Willing Provider
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CMS Innovation Center
CMS Innovation Center Charge
Accountable Care Act
“Test innovative payment and service delivery models
to reduce program expenditures, while preserving or
enhancing the quality of care”
Three aims
Better care for individuals
Better care for populations (e.g., certain diagnosis)
Lower growth of expenses
$10 Billion in funding for FY 2011-2019
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CMS Innovation Center
Pioneer ACO Program
Advanced Payment Initiative
Bundled Payments
Comprehensive Primary Care
Health Care Innovation Challenge
Independence at Home Demonstration
Note: No double dipping (in certain cases)
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What is an ACO?
Accountable Care Organization (ACO)
Eligible participants
5,000 Beneficiaries
Tax identification number (TIN)
Legal entity
Shared savings/losses
Quality measures
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What is an ACO?
Some payors want to work with providers in a new
“accountable” era
“Commerical-ACOs”
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Quality
Pay for Performance
Readmissions
Value Based Purchase (VBP)
Ensure that patients who may have had a heart attack
receive care within 90 minutes
Provide care within a 24-hour window to surgery
patients to prevent blood clots
Communicate discharge instructions to heart failure
patients
Ensure hospital facilities are clean and well maintained
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Quality
Public reporting
Hospital Compare
Physician Compare (coming soon)
Patient Surveys
Qualified Entities
Appeals/Corrections
Selection of quality indicators
What is a good score?
Data
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Cost Containment
What is the Relationship between Cost and
Quality?
Why do we care now?
Aging of population
Tough economic times
Shift in care setting
ACOs
Medical homes
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Cost Containment
Waste
Freedom of Choice
Consolidation
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Technology
“People need to be assured that their health records are
secure and private. I feel equally strongly that
conversion to electronic health records may be one of
the most transformative issues in the delivery of health
care, lowering medical errors, reducing costs and
helping to improve the quality of outcomes.”
Kathleen Sebelius, Secretary of Health and Human
Services, New York Times, May 30, 2011
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Technology
Virtual Care
Telemedicine
mHealth
EHR implementation
Patient safety
Care coordination
Meaningful use
Reimbursement not always there
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Technology
Health plans have data, too
Some want to use it for quality
Focus on population management
Some willing to use it as a tool for providers
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Government Enforcement
Waste
RACs
Fraud and Abuse
Sanctions
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Payor Enforcement
Using government enforcement as a model
Others wanting to work together with providers
Kicking out the bad apples
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Common Provider Frustrations
Lack of leverage and resources to negotiate
contract
Payor insistence on “standard” contract
Dealing with multiple contract components
(manuals, web sites, etc.)
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Key Definitions
Clients and/or Payors
Covered Services
Medical Necessity
Standard of Care
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Provider Obligations
Maintaining Records
Uniformity across contracts
Consistency with Federal and State law requirements
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Provider Obligations
Audits
Which party is responsible for audit costs?
What documentation is subject to audit?
Is the Payor required to provide advance notice?
Are audit rights limited to a prescribed “look back”
period?
May the Payor use statistical sampling or
extrapolations as a basis of an overpayment claim?
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Provider Obligations
Policies and Procedures
Must modifications be provided to Provider in
advance?
Can the Provider object to modifications?
In the event of a conflict, does the base agreement or
the manual control?
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Provider Obligations
Utilization Management
Is the Provider’s right to appeal clearly delineated in
the contract?
Does the contract require Payor to respond to
preauthorization requests within a specific period?
Is the authorization an irrefutable verification of
eligibility?
Does the Payor maintain ultimate responsibility for
decisions of medical necessity?
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Claims Submission and Reimbursement
Time Period and Process
Obligation to Pay
Nonpayment
Retroactive Denial of Claims
Coordination of Benefits
Payment Based on a Percentage of “Then Current
Fee Schedule”
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Term and Termination
Contract Term
Is the provider “locked-in” for a multi-year period?
Without Cause Termination
For Cause Termination
Is there a cure period?
How much discretion does the Payor have to terminate
“for cause”?
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Term and Termination
Transition Rights and Obligations
Transition of Care and Continuing Care Obligations
Communications to Members
Dispute and Appeals
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Other Provisions
Government Program Provisions
Amendments
Insurance
Indemnification
Assignment
Changes in Law
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Questions
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More questions, please contact us.
Sarah E. Swank
Ober|Kaler
Alan J. Arville
Ober|Kaler
202.326.5003
[email protected]
202.326.5020
[email protected]
Dennis G. Hursh
Hursh & Hursh
717.930.0600 · 866.DOC.LAW1
pahealthlaw.com
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