Managed
Care
Contracting techniques are the bread and
butter of healthcare administrators. Sometimes it is a good idea
to review a primer to refresh our memories. I would like to share
some of the practical ideas I have found useful.
Scan contracts or get them on disks. This
allows you to search for key words and phrases. I heard a contract
sage once say that "verbs cost money." My experience is that adverbs
and adjectives have price tags, too. The word processor's search
function allows you to find quickly and highlight such key money
words as: shall, perform, adequate, appropriate, immediately,
supercede, based on, notwithstanding the foregoing, and from time
to time. We all have certain phrases or conditions to include
in contracts.
Consider developing a computer file of
these to cut and paste them easily into the contract. Use color
codes to highlight such areas you wish to add, delete, clarify,
etc. We should remember that a contract author's prerogative is
to define what terms mean. Negotiators can generally agree on
what is meant by a word or phrase in question. Remember, though,
to get the clarifications and definitions included in the addendum.
It can be costly to assume that you are "speaking the same language."
The phrase "use best efforts" is a good
way to help modify language. This will help avoid being technically
in breach of a contract. For example, coordination of benefits
between two health plans sometimes takes time. A contract may
stipulate that coordination take place at the patient's admission.
The reality is that problems and delays do occur when coordinating
benefits. Agreeing to "use best efforts" allows you the additional
leeway that is sometimes needed. Reserve the right to send the
primary explanation of benefits (EOB) to the secondary payers.
This can help avoid costly delays and disputes.
And remember to bill at your standard
rates and then calculate the write-off after payment is received.
Develop flow charts on how processes flow and to track withholds.
Such graphics can be helpful and should be attached as an exhibit.
Be sure to insert language that limits
audits only to the health plan's payments and related records.
This will help protect the confidential information and financial
arrangements you have with other plans. Reserve the right to bill
a plan's member for non-covered services.
Finally, be certain to state clearly in
the contract that the health plan is responsible for the information
given to you from their enrollment files.
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