Negotiating Medicaid and Insurance Contracts
Learn essential tips for negotiating contracts with Medicaid and marketplace insurance plans to maximize client health outcomes. Identify key contract terms, negotiation strategies, and opportunities to influence negotiations. Disclaimer: Seek legal advice for reviewing and negotiating health insurance contracts.
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Tips for Negotiating Contracts with Medicaid and Marketplace Insurance Plans Julia Hidalgo, ScD, MSW, MPH George Washington University & Positive Outcomes, Inc. Julia.Hidalgo@positiveoutcomes.net Presented by and 1 Building Capacity Among RWHAP Core Medical Providers to Maximize Client Health Outcomes in an ACA Environment
Learning Objectives: By the end of this webinar, you will be able to: Interpret key contract terms or provisions Identify strategies for negotiating contract terms Strategize opportunities to influence contract negotiations when your HIV program is part of a larger organization Disclaimer: Seek legal advise in reviewing and negotiating health insurance contracts 2
8 Essential Actions for Contracting Action 1. Enhance Current Contracts Action 2: Establish New Contracts Action 3: Market Your Services Action 4: Negotiate Contract Terms Action 5: Increase Client and Community Awareness Action 6: Evaluate Costs Action 7: Evaluate and Improve Contracts Action 8: Improve the Revenue Cycle to Maximize Revenue
CONTRACTS TERMS BEGIN WITH THE PURCHASER State Medicaid MCO ACA QHP Other Types of Insurers Employer Federal Government Insurance Commissioner Medicaid Purchaser Insurer Provider
Do Your Homework For Medicaid MCOs, get the State s model contract, request for proposal (RFP), or relevant regulations Get the contract and all related materials The negotiation team should read the materials thoroughly 5
Key Terms: Basics Contract period Insurance coverage and indemnity Dispute resolution Advance notice of changes in the terms Breach Renewal Termination Eligible beneficiaries 7
Key Terms : Services Covered services and definitions Non-covered services Formulary 8
Key Terms: Services Practitioner choice and changes Clinician credentials Referrals Medical necessity and prior authorization Access standards 9
Key Terms: Payment Claims submission Clean claims Payment methods, amounts, and timing Fee for service, capitation, pay for performance Under and overpayment payment Dispute resolution 10
Educate The Negotiation Team About HIV Services Terms with a negative impact on quality or payment adequacy Offer HIV-related terms Educate the negotiation team about: HIV care continuum Clinical staffing model Visit frequency and duration Formulary adequacy Array of services offered: preventive, clinical, care management Adequacy of payment models 11
Time to Negotiate Negotiate separately to avoid antitrust Develop an tailored negotiation strategy Identify key contract objectives and priorities Set the criteria for walking away from the negotiation Seek common ground 12
Negotiation Strategies Never accept a contract without careful review Understand contract terms so that you can ask the right questions Identify negotiable terms Offer alternative terms to address your concerns Start early before the service period begins 13
Key Resources Academy of Managed Care Pharmacy. Managed Care Terms: http://www.amcp.org/ManagedCareTerms/ Broussard I. Analyzing Managed Care Contracts. Practice Management Institute. http://www.akrongeneral.org/portal/page/portal/AGMC_PAGEGROUP/practiceman agement/AnylzMgmtCrCntrcts.pdf CAI. From Survival to Success: An Introduction to Managed Care Contracting. http://cba.caiglobal.org/index.php/2015-01-13-15-21-17/an- introduction-to-managed-care-contracting Falcone AJ. Technical Assistance: Negotiating Contracts with MCOs: 2012 Ryan White Meeting: https://careacttarget.org/library/negotiating-contracts-managed-care-organizations Nelson P. Managed Care Contracting- Terms and Termination Clauses: http://www.mcres.com/mcrmcc13.htm Ziel S. A Checklist for Reviewing Managed Care Contracts. http://ispub.com/IJANP/1/2/5245http://ispub.com/IJANP/1/2/5245 14
Webinar Highlights Earlier CRE webinars addressed steps to contracting, including contracting basics and marketing strategies Review all relevant contracting documents before negotiations begin Identify key contract terms Strategies for negotiating contract terms Influencing contract negotiations when your HIV program is part of a larger organization Technical materials to help prepare your team 15
