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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