Share
Explore BrainMass

Managed Care Contract Model

You are a provider relation's director of an MCO. Prepare a contract proposal outline for a large medical group to consider. Be as specific as possible. Please cite resources.

Solution Preview

A provider contract has certain sections that are standard to any legal contract.
It is customary that it will contain
A) The name of the parties involved using their legal names as those will be the one used to enforced the contract.
B) The term of the contract- spelling when it is effect and when it will terminate. Standard contract can have duration of 1 or 2 years.
C) Physician responsibilities. This part is usually detailed in the contract and will include as minimum (a)hours required to work per week and on-call per month (evenings or weekend that physician will be required to answer emergency calls), (b) comply with standard of care established by the insurance or MCO, (c) timely filling of claims for payment of services done, (d) non-discriminatory clauses- cannot discriminate based on age, race, sex, national origin, religion, medical condition or health status including on the basis that a patient is a member of the health plan (no limit on patients seen participating in the plan), and (e) remain licensed or registered to practice medicine and in good standing with the state in which it is chartered and each state in which it is doing business.
D)Managed Care Responsibilities
E)Physician Compensation,
F) Malpractice insurance responsibility,
G)Any restrictive clauses including privacy and nondisclosure,
H)Causes for termination of agreement, and
I) how the disputes will be solved.

A contract proposal should have as minimum the areas of most interest to the provider of services and the MCO in able to start negotiations that can lead to the signature of the contract. The following is based on the 2005 American Medical Association's Model Managed Care Contract. Document has been attached. (None of the exhibits are included. This is only for guidance.)

THIS CONTRACT PROPOSAL OUTLINE made this 29 day of April 2011 and will be effective until the 29 day of May, 2011 by and between LA ROCCA Internal Medicine Practice ("LA ROCCA"), and Healthy Living a Utah Managed Care Organizations ("MCO")

WHEREAS, MCO offers or directly administers one or more health benefit products or plans and wishes to arrange for the provision of medical services to Enrollees of such products or plans.
WHEREAS, LA ROCCA is comprised of or contracts with one or more
physicians capable of meeting the credentialing criteria of the MCO.
WHEREAS, MCO desires to engage LA ROCCA to deliver or arrange for the delivery of medical services to the Enrollees of its plans.
WHEREAS, LA ROCCA is willing to deliver or arrange for the delivery of
such services on the terms specified herein.
NOW, THEREFORE, in consideration of the mutual promises set forth herein, and other good and valuable consideration, the parties hereby agree as follows:

I.Definitions
Please refer to Exhibit A

II.Delivery of Services
2.1 LA ROCCA shall provide or, through its Qualified Physicians, arrange for the provision to Enrollees of those Covered Services that are identified ...

Solution Summary

The solution involves explaining the importance of the different parts in a managed care contract, an outline of a mock contract, and references for further information. It also has an attachment of a Model Managed Care Contract from the American Medical Association.

$2.19