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Format: On-Demand Webinar
Presenter: Michael R. Lowe, JD, ESQ.
Time: You can access the webinar anytime
Duration: 90 minutes
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This webinar is designed to educate entities that contract with Managed Care and private insurance companies on the critical provisions in Managed Care contracts, as well as how to address third-party pay in such contracts and before they become issues for the entities. The webinar will cover the critical provisions that an entity should focus on when contracting with a Managed Care for private insurance companies, how to combat silent PPOs, addressing gag clauses and other prohibited language and provisions in Managed Care contracts, and negotiations and strategies to employ when contracting with Managed Care entities and private insurers. This webinar will include a PowerPoint presentation which the attendees will be able to download and use for future reference. It will also include a Question-and- Answer session at the end of the webinar.

You can create successful managed care contracts with more flexibility including how much reimbursement you receive. If you’re negotiating with a payer for the first time, or trying to modify an existing agreement, you must master the key components of the contract. Healthcare attorney Michael R. Lowe, Esq., will provide you a step-by-step process so you can quickly evaluate your payer contracts, identify hidden opportunities, and negotiate to maximize your reimbursements.

Learning Objective:

  • What are the five (5) most important provisions to look for in a draft MCO contract?
  • Why do you cross-reference and check exhibit references in the contract?
  • How does the definition of medically necessary and emergency Services interrelate to the covered and non-covered services provisions?
  • What is economic credentialing and how do you spot it in the contract?
  • Should you ever sign a contract that allows an MCO to retroactively deny claims?
  • Should the contract contain any provisions that allow the MCO to unilaterally deny claims based on medical necessity?
  • How should you address unilateral medical necessity provisions?
  • Where would you find the medical necessity appeals process in your contract?
  • What other manuals are important in a contract?
  • When in the negotiation process should you receive and review the important manuals
  • Should you “test-drive” the MCOs provider portal prior with a live person to walk you though and be able for real-time questions and answers prior to signing or after signing the contract?
  • What to look for in Balance Billing in the MSO contract?
  • What is a Gag Clause and are they illegal?
  • What administrative burdens should be addressed as part of the contracting process?
  • Is it important for you to not only receive a copy of the final agreed to and fully executed (including dates) version of the contract for your files, but to do a complete line by line review to ensure that what each party has signed matches the agreed to final version that was not signed?
  • Strategies for negotiating Managed Care Contracts
  • Identifying critical provisions for negotiation

Areas Covered in the Session

  • Overview of Managed Care Contracting
  • Critical Provisions to Consider in Any Managed Care Contract
  • Credentialing
    • The National Committee for Quality Accreditation (NCQA)
    • For-Profit Credentialing Verification Organizations
    • Medical Associations and State Medical Boards
      • American Medical Association
      • Federation of State Medical Boards
      • American Board of Medical Specialties
    • Government Agencies
      • National Practitioner Data Bank
    • What is Credentialing?
    • Why Do Managed Care Companies Perform Credentialing?
    • Who Performs Credentialing?
    • What is Economic Credentialing?
  • Necessary Steps to Take When Applying to a Managed Care Plan
  • Deselection
    • Why Do MCOs Deselect Physicians – The Bottom Line
    • Are Deselections Legal?
    • For Cause Versus No Cause Deselections
    • What Should You Do If You Are Deselected by a Managed Care Plan?
  • Applicable Florida Legislation
    • Balance Billing (Section 641.3154, Florida Statute)
    • Florida Prompt Pay/Clean Claims Statute (Section 641.3155, Florida Statutes)
  • Introduction – Silent PPOs
  • What is a Silent PPO? Recognizing Silent PPO Transactions
  • The Difference Between Silent PPOs and Traditional PPO Networks
  • Silent PPOs
    • Warning Signs/Detection of Silent PPO
    • Review EOBs carefully
    • Red flags
    • Silent PPOs – Traditional PPO Industry -Pre 1990s
    • Silent PPOs The tangled web: the rental network PPO industry
    • Identifying Silent PPOs
    • A successful audit requires the provider to have in place the following operational features
    • How Silent PPOs Persist
    • The Underlying Problems
    • Lack of “Transparency” as a Cost Reduction Strategy
    • Specific Payment Reduction Strategies
    • An Unregulated Secondary Discount Market
    • Combating Silent PPOs
    • Protections Against Silent PPOs

Suggested Attendees

  • Physician Group
  • Practice Administrators and Managers
  • Individual Physicians
  • Billing Coordinators and Managers
  • Healthcare Providers
  • IDTF Administrators
  • Ambulatory Surgical Center Administrators
  • Healthcare Billing Consultants
  • Medical Billing Companies
  • Independent Lab Owners/ Administrators

About the Presenter

Michael R. Lowe, JD, Esq. is board certified in health care law by The Florida Bar and is an AV-rated attorney. His practice focuses on all aspects of business, corporate, transactional, litigation, regulatory, operational and administrative matters in the health care law arena. Emphasizing the representation of physicians and physician group practices, Mr. Lowe regularly represents clients in litigation, medical records and HIPAA privacy regulations issues, managed care contracting and reimbursement matters, the preparation, review and negotiation of physician employment agreements, Medicare/ Medicaid fraud and abuse prevention, federal Stark Law matters and analysis, defense and reimbursement issues, ACA matters, medical staff privilege cases, professional licensure and disciplinary actions, voluntary self-disclosure cases, physicianhospital contracts, compliance plan development, and health care regulatory analysis and counseling matters. Mr. Lowe’s practice also includes the representation of hospital medical staffs, IPAs, ambulatory surgery centers, durable medical equipment providers, diagnostic imaging centers, hospitals, long-term care facilities and other health care professionals and providers.

Licensed in both Florida and Georgia, Mr. Lowe is a member of the health law sections of the Florida Bar, Georgia Bar and American Bar Associations. Additionally, he is a member of the American Health Lawyers Association. Mr. Lowe was evaluated by his peers as a “preeminent” attorney, and awarded the “AV” rating by Martindale-Hubbell. The “AV” rating identifies a lawyer with preeminent expertise, experience, integrity, and overall professional excellence.

Mr. Lowe has written numerous articles on a variety of health law issues of concern to physicians, practice managers, and health care organizations throughout the country. He is a frequent lecturer on various health care law topics for local, state and national groups. Mr. Lowe received his B.S. degree in history from the United States Naval Academy and his M.A. degree in national security studies from Georgetown University, and is a former naval aviator and Desert Storm veteran. Mr. Lowe graduated summa cum laude from the University of Alabama School of Law, where he earned his J.D. degree.

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  • Webinar Link + Handouts PDF
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