1. Is the payment method clearly defined? Are there per diems, diagnosis-related groups, California Relative Value Studies or Current Procedural Terminology?
2. Can the payment method be easily adjudicated?
3. Are there provisions for limiting provider risk, such as stop-loss provision or minimum payment thresholds (hospital only)?
4. Are there late payment penalty provisions? If yes, are they easy to administer?
5. Are billing requirements consistent with standard provider practice; that is, are there billing forms and procedures?
6. Do payment provisions include a most-favored-nation clause (hospital only)?
7. To what extent are payment provisions tied to utilization review requirements?
8. Are service categories properly defined for purposes of payment (for instance, diagnosis-related groups or ICD-9)?
9. Are time restrictions included for billing?
10. Are mechanisms included for expedited payment? If so, are they easy to use?
More Articles on Managed Care Contracts:
New Hampshire Proposes 3 Managed Medicaid Contracts; Groups Call for Public Review
11 Managed Care Contract Questions Regarding Termination
5 Points on Managed Care Contracts
Becker’s 3rd Annual Fall Chief Pharmacy Officer Summit is the top tier event that the people leading the future of pharmacy convene. This 3-day event is built specifically for Chief Pharmacy Officers and senior pharmacy leaders. The sessions examine the workforce, financial and clinical priorities shaping pharmacy today. Becker’s is where candid discussions flourish and new ideas thrive. Becker's 3rd Annual Fall Chief Pharmacy Officer Summit
