Before You Sign

No contract is set in stone, said panelists at an annual meeting workshop on how to negotiate a managed care contract. Jay Zucker, J.D., of the New York State Office of Mental Health gave the audience a list of questions psychiatrists should ask themselves before signing on the dotted line.

1. Is the contract up to date? Make sure it reflects current state law regarding the operation of managed care organizations.



2. Do you have the whole document? If the contract refers to appendices or other documents, you should obtain and review these as well since they are a binding part of the contract.



3. What is the MCO's policy with regard to amendments to the contract made after you sign? Some contracts may say that the MCO does not have to inform you about these although you will be held to them.



4. Does the contract provide a clear definition of "medical necessity" geared toward psychiatric care? Does it define "medical emergency" in psychiatric terms and include in that definition "danger to self" as well as "danger to others"?



5. Does the contract include a "hold harmless" clause? This clause, which holds the provider, not the MCO, liable in malpractice actions, is illegal in most states.



6. What is the procedure for appealing care denials? As your patients' advocate, you need to know their rights and be able to help them appeal denied care.



7. What is the procedure for providing the MCO with patient information? Make sure that the contract is clear about the circumstances under which you can share information and that the procedure is consistent with state laws on confidentiality.



8. Is there a due process provision for terminating providers from the panel? Make sure the contract includes an appeal process and written justifications for termination.
   
9. What are the payment rates for your services? Are they adequate to cover your costs?



10. What are the billing requirements? What is a "clean" claim? Some contracts include a prohibition against billing for "uncovered services" or stipulate that claims will not be processed unless properly prepared.



11. What are your rights if the MCO doesn't pay you for your services or doesn't pay you within a specified time?



12. What happens to your contract if the MCO merges with or is acquired by another company? Does the contract become null and void? If so, within what period? Will the new company send you a new contract?