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
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