ACP: Practice Management Center - Practice Guides and Other Resources - The Internist's Guide to Negotiating Managed Care Contracts and Capitations Rates

Running a Practice

The Internist's Guide to Negotiating Managed Care Contracts and Capitations Rates

Third, Revised Edition 2002

James B. Wieland, JD, Author
John P. DuMoulin, MS, Editor

Introduction

This guidebook is organized into a series of chapters and sections:

Chapter 1 provides a guide to the various managed care payment methodologies, with a special focus on capitation
Chapter 2 provides a guide to the evaluation of health care plans from the perspective of internists considering individual plan contracts.
Chapter 3 provides a detailed, point-by-point methodology for internists to evaluate the financial adequacy of specific capitation proposals.
Chapter 4 reviews the legal issues that internists can expect to encounter in managed care contracts.
Chapter 5 reviews the administrative issues that internists can expect to encounter in managed care contracts.
Chapter 6 completes the legal review of managed care contracting issues by reviewing liability considerations, ethical issues, and other external legal matters associated with managed care contracts.
Chapter 7 looks at various practice, liability, ethical, and financial issues.
Chapter 8 provides internists with guidance as to their rights when a managed contract is denied or terminated.
The guidebook concludes with a series of appendices that provide working documents for internists to use in day-to-day managed care contracting and in learning to understand managed care contracts.
- Appendix A is a checklist for initial analysis of managed care contracts.
- Appendix B consists of two examples of managed care contracts. The first example is a contract between an HMO and a primary care medical group. The second consists of excerpts from a managed care contract between a subspecialist of internal medicine and an IPA. Both have extensive footnotes guiding internists in their analysis of specific contract terms.
- Appendix C provides guidance for internists in selecting consultants and legal advisers to assist them in their managed care contracting activities.
- Appendix D provides the relative value units published in the 2002 Medicare fee schedule for services commonly provided by internists.
- Appendix E consists of ready-to-copy-and-use worksheets for analyzing capitation rates, as described in Chapter 3.
A glossary is included at the end of this guidebook, defining commonly encountered managed care contract terms.