Managed care contracting is a process that frustrates even the best administrators. However, to ignore this complexity is to do so at your own expense. You don’t necessarily need to bear the cost of overpriced legal advice, but you do need to know what questions to ask, what clauses to avoid, what contingencies to cover ... and when to ask a lawyer for help.
- Decode and analyze reimbursement problems, loopholes, and contract stipulations you are likely to encounter
- Learn tried-and-true tricks, tools, shortcuts, and techniques to evaluate agreements
- Negotiate contracts that won’t leave you open to unanticipated expenses
Written by Maria K. Todd, a seasoned professional in managed care contracting, this handbook is written for managers, analysts, and finance officers who have the daunting task of negotiating contracts for medical services. It offers an in-depth examination of managed care and its organizations and covers key areas, such as pay-for-performance initiatives, reimbursement methods, contract law basics, and negotiating strategies.
The Managed Care Contracting Handbook offers critical details and strategic information as well as resources on everything from HMOs and PPOs to Consumer Driven Health Plans (CDHP), self-funded ERSIA payers, and Medicaid managed care.
Fully updates the first edition, which was used widely in the U.S. and overseas.
Designed to equip you with the confidence that comes with knowing the right questions to ask and more answers than you are supposed to know, this easy-access resource —
- Provides a complete overview of managed care organizations
- Covers contract law basics
- Presents material that can be used internationally
- Discusses Medicaid Managed Care
- Offers an operational evaluation of a typical managed care agreement
- Includes sample contracts and important checklists, as well as a glossary
Table of Contents
What Is Managed Care?
Managed Care Organizations
Dealing with Self-Funded ERISA Payers in Managed Care:
Employee Retirement Income Security Act (ERISA) of 1974
Medicaid Managed Care
Consumer Driven Health Plans: Contracting Implications
Silent Preferred Provider Organizations (PPOs), Secondary
Markets, and White Space Management: Three Terms That
Translate to Revenue Erosion and Frustration
Single-Case and Continuous-Discount Arrangements
Quality Issues in Managed Care (Pay for Performance)
Reimbursement Methods in Managed Care
Strategic Planning for Renewals and New Contracts:
Understanding the Changing Competitive Environment
Developing Business Rules for Better Contracts
Negotiation Techniques, Tactics, and Strategies
Contract Law Basics
Evaluating a Managed Care Agreement—Step-by-Step
Insurance and Managed Care Glossary
Maria K. Todd, PhD, MHA is a professional consultant providing the wealth of her knowledge and practical wisdom to more than 2000 hospitals, physicians, and therapists during the past 25 years. Possessing a depth and diversity of experience matched by few, she has earned a reputation as a peerless expert on managed care. She worked as an EMT and a surgical tech before moving into medical administration and health plan coordination. In addition to degrees in health administration, she is a certified mediator and health law paralegal. A prolific author, she is in constant demand as an award-winning speaker. As a volunteer, she has directly assisted hundreds of senior citizens.
Maria Todd is the most gifted managed care negotiation resource I have ever had the pleasure of knowing. Maria’s vast knowledge is as uncommon as it is welcomed to even the playing field between healthcare providers and payors. Those fortunate providers who take the time to participate in her educational sessions or read her books will undoubtedly achieve unparalleled results.
— Troy D. Roth, Senior Vice President, Revenue Management Strategy, Accuro, A MedAssets Company
Maria Todd's The Managed Care Contracting Handbook is a must-have book for the non-attorney health care professional negotiating managed care contracts for providers. Dr. Todd combines a thorough discussion of managed care contracting basics with helpful hints and practical tools for contracting with all types of payor organizations all with an easy to comprehend style. Dr. Todd brings what could be very dry material to life.
— Ellen E. Stewart, MSHA,JD,FHFMA, Partner, Berenbaum, Weinshienk & Eason, PC Denver, Colorado
Many organizations struggle to optimize their managed care strategies to achieve operational and financial success. Maria Todd's new book could be the missing keystone to achieve that success. This is a must-read for every hospital executive involved in the managed care process - clinical and financial leaders alike. Clearly and concisely, Maria Todd lays out the background of managed care in all its complexity. Most importantly, she offers proven methods for planning, negotiating, executing, and evaluating managed care contracts that will withstand legal and operational challenges. Maria is well known for her knowledge, good judgment, and commitment to the industry, and her newest book should be used as a key part of any healthcare provider's managed care strategy.
— David Hammer, MBA, MHS, FHFMA, CHFP, Vice President, Revenue Cycle Solutions McKESSON Provider Technologies
Dr. Todd does a marvelous job at taking the most complex issues of contracting and bringing them down to the level of understanding and simplicity. Using years of real life experiences and making them relevant to our world of contracts is brilliant. It is sad to have Dr. Todd point out how much trouble the insurance industry goes through to make us believe we are getting fair and useful contracts to manage our patients with.
— Lawrence M. Preston, MBA, FHFMA, President and CEO, Professional Medical Consultants, Inc.
I have utilized Maria Todd’s materials for many of my engagements. She has her finger on the pulse of the managed care industry and is an important resource for my consulting business.
—Catherine M. Zito, FHFMA, CPA, Healthcare Financial Consultant
As a certified managed care professional, Maria Todd has done it again! The 2nd Edition is even better than before. For example, her process for setting case rates is pure genius! Until I read this section, I didn’t fully grasp the ramifications of setting case rates without the requisite level of detail in the contract. In just a single passage, Maria Todd challenged me to dig deeper into an area in which I previously thought I had true expertise. ... this book is a must-read for improving the professional development of everyone dependent upon managing and negotiating accurate and real-world managed care contracts.
— David I. Samuels, FHFMA, MPA, 2008-09 President-Elect, HFMA/Nevada Chapter, President, EthiCare Breakthrough Solutions, Inc.
The Managed Care Contracting Handbook should be required reading for ALL hospital managers regardless of the department they manage. The issues and solutions Ms. Todd addresses can mean the difference between barely surviving and successfully thriving for healthcare providers.
— Jackie Hodges, President, HRC Solutions
I know I can rely on Ms. Todd to clearly define and simplify complex issues. Not only does it help my understanding, but assists me in conveying complicated issues to others. I have consistently found her recommendations and tools to be practical and useful.
— Ed Casteel, Divisional Managed Care Director, Mississippi Division, Health Management Associates