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Class Description:

MEDICAL SERVICE AGREEMENTS WITH SYSTEMS-BASED CARE ORGANIZATIONS

This class examines the medical service agreement between physicians and systems-based care organizations. This agreement governs what the systems-based care organization’s will and will not pay for, what services can be provided without question, what services require prior permission, and perhaps the process by which exceptions are made. This agreement has the formula that tells how much providers are going to get paid. This class distinguishes basic terms of provider agreements with systems-based care organizations and how these terms effect the provider. Also, this class analyzes various payment mechanisms and how these mechanisms effect the provider. In addition, this chapter examines specialty contracting.

Topics:   

MEDICAL SERVICE AGREEMENTS WITH MANAGED CARE ORGANIZATIONS

I.     PCP Contracts

II.     BASIC CONTRACT STRUCTURE

III.     COMPENSATION PROVISIONS

IV.     TERM AND TERMINATION PROVISIONS

V.     UTILIZATION REVIEW AND QUALITY ASSURANCE

VI.     MISCELLANEOUS PROVISIONS

VII.     PAYMENT MECHANISMS

VIII.     SPECIALTY SERVICE CONTRACTING

Key Objectives:

  1. Distinguish basic terms of provider agreements with systems-based practice and how they effect providers.
  2. Analyze various payment mechanisms and how they effect providers.
  3. Summarize specialty contracting.

Review:

  1. Explain the basic structure of a typical systems-based practice’s contract with Primary Care Physicians.
  2. Explain the advantages and disadvantages of withholding pools or bonus payments for efficient utilization as used in medical service agreements.
  3. Explain four factors for success in specialty service contracts.