April 12, 2013 Monica Powell-Gerald, MHSA Director, Innovative Care - - PowerPoint PPT Presentation

Exchange Contracting Checklist Overview April 12, 2013 Monica Powell-Gerald, MHSA Director, Innovative Care Networks PCA/Network Relations mpgerald@nachc.com

Exchange Contracting with a Previously Contracted Insurer/Issuer

• Be cognizant of the fact the each

Agreement/Amendment builds upon the other

• Pay attention to new terms that are introduced via the

proposed amendment

• Issuer may “delete and replace” language using the

Amendment which may negate any previously negotiated language

• Amendment may alter other contract provisions or

previously negotiated fee schedules

New Agreements with QHP Issuers

• Become familiar with the contract documents
• Make certain that the roles and responsibilities of both

the CHC and the Issuer are clearly defined by the proposed Agreement

• Closely examine provisions related to new product

introductions and contractual amendments

• Review Utilization Management Guidelines
• Conduct a in depth review of Issuer policy and

procedure manuals

State and Federal Regulations

• Become familiar with references to state and federal

laws and regulations found in the proposed agreement

• Gain familiarity with recent federal guidance related to

QHP network development, structure, function and monitoring

• Become knowledgeable of payment requirements for

exchange products

Review ALL Associated Contract Documents Common Contract Documents Include:

• Fee Schedules
• Utilization Management Program Guidelines
• Policy and Procedure Manuals
• State Regulatory Attachments

CHC and Issuer Responsibilities

Contract should clearly define the responsibilities of CHC and Issuer/Insurer

• Scope of Services Provided
• Credentialing
• Claims Submission and Payment
• Payment disputes and overpayments
• Amendment Process

Negotiating A Competitive Fee Schedule

• Conduct a complete review of the proposed fee

schedule in conjunction with CHC CFO

• Compare your current PPS rate to those rates

proposed by the Issuer/Insurer

• Request a sample fee schedule from the

Issuer/Insurer (generally the top 20 most commonly billed codes)

• Utilize the fee schedule carve-out mechanism to

establish fees for services that are substantially undervalued by Issuer/Insurer

Contractual Updates and Policy Modifications

• Include language that requires 30-45 days prior

written notice for updates to policy and procedures and other contractual modifications

• Propose language that gives your organization 30

days to respond to any proposed contractual modifications or amendments

• Protect your organization from the introduction of

new products that may have alternative fee schedules by requiring notification of and a 30 day review period to respond to the proposed changes

Term and Termination Provisions

• Set contract term limits that minimize your risk
• Should you decide to terminate the agreement set a

reasonable notification timeframe

• Examine closely the reasons that the Issuer/Insurer can

terminate the agreement, if possible, make these provisions mutual

• Review termination provisions with legal counsel

Outline Eligibility Verification Mechanism within the Document

• Can eligibility information be verified 24/7?
• Is eligibility information available real-time?
• How frequently are Issuer eligibility files updated?
• How should provider handle claims that are denied due to

erroneous eligibility?

Non Payment of Member Premium

• Address how payments for denied claims are handled

in instances where premium remains unpaid following the expiration of the 90-day grace period

• Identify the party responsible for the payment of claims
• Identify the process to follow for reprocessing and

paying these claims (re-submission or special project)

• Outline the timeframe for initiating and completing this

activity

Questions?????

For More Information Contact: Monica Powell-Gerald, MHSA Director, Innovative Care Networks National Association of Community Health Centers Email: mpgerald@nachc.com