Managed Care Contracts

Managed care is a health care delivery system organized to manage cost, utilization, and quality. Every healthcare provider must settle on a managed care contract between itself and the payer.

According to Findlaw.com, the contract between a clinical laboratory or other health care professional and a managed care organization (MCO) such as a provider-sponsored network, integrated delivery system, health maintenance organization, or other health care plan, is the fundamental document which frames, defines and governs their relationship. Contractual provisions can affect payment, office organization, practices and procedures, and confidential records as well as clinical decision-making.

Findlaw states, “A good managed care contract, like any other form of business agreement, is clear, consistent, comprehensive, and concise. It will conform to both the intent of the parties, setting out their respective rights and responsibilities, and the requirements of state and federal law.”

For example, Medicaid managed care provides for the delivery of Medicaid health benefits and additional services through contracted arrangements between state Medicaid agencies and managed care organizations (MCOs) that accept a set per member per month (capitation) payment for these services.

Depending on the market share of the health plan and the services offered by the healthcare provider, the negotiability of the contract will vary. Well-established managed care plans that have a large market share typical use form contracts. Newer managed care plans that have little market share and want broad provider participation are generally more willing to negotiate terms.

The Patient Protection and Affordable Care Act and the move toward accountable care has put a much greater emphasis on quality measures than in previous years.

Healthcare providers must prove in contract negotiations how well they manage quality and cost; such proof is usually provided with a comprehensive set of quality measures reported directly from the electronic health record (EHR). This can be straightforward for a single practice using the basic reporting functionality of its EHR, a more complex managed care plan might require features that an EHR vendor doesn’t offer.

Reacting to PAMA Cuts, Lab Works with Payers

CEO SUMMARY: Before Medicare’s lab test price cuts went into effect last year, Health Network Laboratories began discussions with private health insurers and nursing home clients about the possibility of renegotiating their contracts. In these discussions, HNL promoted the value it deli…

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In Florida, More Tests Added to UHC’s Decision-Support Program

IN THE FIRST BROAD EXPANSION OF ITS pilot decision-support program for clinical lab testing in Florida, UnitedHealthcare (UHC) will add genetic and molecular tests, drug tests, and pathology procedures, among other assays starting in two months. On March 1, UHC will expand its labor…

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UHC, LabCorp Play Hard Ball With Texas Lab Contracts

CEO SUMMARY: In launching BeaconLBS in Texas, UnitedHealthcare included a new, more onerous twist than it used for BeaconLBS in Florida. To be a BeaconLBS in-network ‘lab of choice,’ a lab must be in the lowest quartile for lab test prices. Any lab above the 25th percentile would have…

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Quest Makes Second Deal For Inpatient Lab Volume

NEWS OF A HOSPITAL INPATIENT LAB MANAGEMENT AGREEMENT between HealthONE of Denver and Quest Diagnostics Incorporated marks the second time in six months that the public lab company has earned an inpatient lab management pact with a multi-hospital health system. Ther…

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Payers Asking for Repayment When Labs Waive Fees

CEO SUMMARY: Health insurers appear to have stepped up their efforts to warn clinical laboratories not to waive patients’ fees in return for specimen referrals. Consultants also say that payers are increasing enforcement efforts. There are cases where, when insurers discover labs have n…

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LabCorp, Quest Diagnostics Both Say 2014 Revenue Was Up

BOTH OF THE NATION’S LARGEST clinical laboratory companies reported increased specimen volume as a result of the Accountable Care Act (ACA), as noted in their respective fourth quarter and full-year earnings reports. First to issue its earning statement was Quest Diagnostics Incorporated. On…

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In this Philadelphia Story, LabCorp Uses 2007 Script

CEO SUMMARY: There’s a managed care contracting play-book that seems to be working better for Laboratory Corporation of America than it does for Quest Diagnostics Inc. On July 1, LabCorp became the exclusive national lab provider for Independence Blue Cross of Philadelphia. For the past…

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Aetna Threatens to Expel Docs for Out-of-Network Lab Referrals

MANAGED CARE PLANS are taking aggressive steps to keep clinical lab testing within their preferred networks. In particular, Aetna, Inc., is earning a reputation as one of the toughest insurers in this regard. Most recently, in a letter sent to at least one network physician, Aetna w…

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Aetna To Lower Lab Test Prices, New Fees Are Effective on July 1

IN RECENT MONTHS, labs are reporting the receipt of letters from Aetna, Inc., announcing that it will pay dramatically less than Medicare prices for many key lab tests. Aetna said that these lower prices will take effect on July 1, 2013. Three examples illustrate the deep fee cuts t…

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Lab Copays Announced by California Exchange

CEO SUMMARY: California will operate one of the nation’s largest health insurance benefit exchanges, as defined by the Affordable Care Act. Officials recently unveiled details about the exchange, to be called Covered California. Based on bronze, silver, gold, or platinum plan coverage, …

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