Managed care organizations have to pay state rates for two years. How much freedom/flexibility is there from regulations for alternative payment rates?
Plans have flexibility. State agencies have indicated that they are interested and open to alternatives but approval will be needed.
How receptive are plans to the negotiation of contracts?
The managed care organization is going to start with its own template agreement for the type of service but contracts are negotiable. For example term and termination are definitely negotiable, assignment can be negotiable. On the other hand compliance with laws is not going to be negotiable. If planning to negotiate a lot of the provisions providers may want to consult with a lawyer. But often plans do not use lawyers in favor of provider contract teams. During negotiation, focus on things that are important from a business perspective. Remember some, like "performance standards," may not be in the main contract; they may be in appendices.
If managed care organizations are not mandated by NYS to contract with providers, will plans still give other providers contracts?
Plans may offer contracts to providers other than those they are mandated to offer contracts to. Please refer to slide 15 of "Contracting and Credentialing."
Is there a reason that managed care organizations would not want to contract with a provider?
Managed care organizations may not want to contract with a provider because of geographical coverage, cost, or concerns about quality of care.
Any advice for Adult Home and Community Based Services(HCBS) in terms of contracting with managed care organizations?
There is nothing unique about HCBS from a contracting perspective, but from a quality perspective and an accountability perspective there is a lot of scrutiny over those services. For example, did the member receive what they were supposed to receive (i.e. hours)? Generally it's going to be the same contract template but with some unique features in terms of performance requirements that plans may be focused on. It's important that the providers capture and document the services. The plan also has to ensure that those services are being provided in the home and community based setting.
How will HARP contracts vary from mainstream managed care contracts?
HARP plans have the same contractual requirements. There is not a separate HARP contract; it is the same as that of a mainstream managed care plan.
What is the definition of medical necessity?
The New York State Department of Health defines medically necessary as: "health care and services that are necessary to prevent, diagnose, manage or treat conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with such person's capacity for normal activity, or threaten some significant handicap."
What is the optimal background for the provider point person in the managed care contracting process?
Someone of a high level in the provider organization, who has broad knowledge of the organization and the members that you serve, and who can communicate with high levels within the managed care organization would be optimal.
What can providers expect in terms of potential auditing from the managed care organizations?
This depends on the managed care organization so review your individual contracts. Managed care organizations have the right to audit providers for various reasons. Specifically, reimbursement for services to make sure that there's documentation to support the claims that providers submit as well as for the quality measures that the plans are valuated on. Managed care organizations are entitled to reasonable access to information. Reasonable access presumably means notifying providers in advance, allowing providers to schedule the audit when they do not already have another plan auditing that day, and not interrupting or interfering with provider operations.