ama’s national managed care contract and database wes cleveland, jd american medical association...
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AMA’s National Managed Care Contract and Database
Wes Cleveland, JD
American Medical Association
312.464.4503
© 2012 American Medical Association. All rights reserved.
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Origin ─ Physician Perspective
• Many physicians continue to face take-it-or leave it managed care contracts that contain or lack terms not tolerated in other industries.
• Over two decades of managed care regulations and laws, but ongoing complaints regarding compliance.
• The “regulatory addendum” approach not entirely satisfactory.
© 2012 American Medical Association. All rights reserved.
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Origin ─ Insurer Perspective
• National health insurers complain about the administrative burden they suffer trying to comply with varying state mandates.
• Estimates at $400 million saved annually.
© 2012 American Medical Association. All rights reserved.
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Process
• Challenge posed to national health insurer ─ why not just develop a nationally compliant contract?
• In response, one national insurer represented that it would consider such a contract if developed.
© 2012 American Medical Association. All rights reserved.
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Process
• Developed in coordination with AMA/Federation workgroup
• Replaces the aspirational approach adopted by the AMA’s Model Managed Care Contract
• Based on statutes and regulations of all states, DC, and federal.
© 2012 American Medical Association. All rights reserved.
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Structure-NMCC• NMCC contains detailed
provisions/citations addressing issues such as:
– disclosure of fee schedules and other matters affecting payment;
– claims submission;– claims processing;– physician-patient communications;– physician-patient advocacy;
© 2012 American Medical Association. All rights reserved.
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Structure-NMCC– credentialing;
– preauthorization and verification;
– overpayments and underpayments;
– dispute resolution;
– amendment;
– penalties for delayed claims processing;
© 2012 American Medical Association. All rights reserved.
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Structure-NMCC– all products clauses;
– most favored nations clauses;
– physician profiling and tiering;
– secondary market activity; and
– termination.
© 2012 American Medical Association. All rights reserved.
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Structure-database
• NMCC database fully searchable by topic, word, statutory or regulatory citation, state/federal, or AMA policy.
• Searches retrieve NMCC text, full text of laws and regulations, AMA policy, and/or issue briefs on important managed care topics.
• Text of NMCC and supporting database continually updated to reflect current statutory and regulatory requirements.
• Access www.ama-assn.org/go/nationalcontract
© 2012 American Medical Association. All rights reserved.
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On-line community
• Join the new “Cutting-Edge Contracting Group” online community
– Physicians, practice staff, and others who assist physician practices will be able to discuss contracting issues and share success stories with respect to all practice contracting, not just managed care contracting.
– Sign up at
www.ama-assn.org/go/contractinggroup. Those who sign up can receive a copy of the NMCC.
© 2012 American Medical Association. All rights reserved.
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Practice Management Alertswww.ama-assn.org/go/pmalerts
Four steps:– (1) Identify all of the services to be included in the
budget;– (2) Predict accurately the extent to which your
expected patient population will utilize those services. To do this, you will need the specific data sets—level of transparency will be revealing. Supplement with your own practice data: “Take charge of your data: The physicians’ guide to reviewing and using claims data to improve their profiles, practices and payment.” www.ama-assn.org/go/physiciandata
© 2012 American Medical Association. All rights reserved.
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Sign up for Practice Management Alerts• New toolkits, resources and webinars, e.g.,
managed care contracting, administrative simplification, profiling, emerging payment and delivery models
• Unfair payer practices and how to effectively address them
• Tailored to each physician practice’s needs• Free of charge
www.ama-assn.org/go/pmalerts
© 2012 American Medical Association. All rights reserved.
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Additional Public Resources• “ACOs, CO-OPs and other options: A
‘how to’ manual for physicians navigating a post-health care reform world”
– Introduction: “Complex environment-difficult choices;”
– Chapter 1: “Accountable care organizations—overview;”
– Chapter 2: “Accountable care organization governance issues”
– Chapter 3: “Partnering with hospitals to create an accountable care organization;”
© 2012 American Medical Association. All rights reserved.
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Additional Public Resources– Chapter 4: “Partnering with health insurers to create
an accountable care organization;”
– Chapter 5: “CO-OPs and accountable care”
– Chapter 6: “Guidance on earning electronic health records incentive payments;”
– Chapter 7: “Managing antitrust risk associated with accountable care organizations”
– Chapter 8: “Hospital physician employment agreements”
– Chapter 9: “Retaining independence while embracing accountability: Care coordination and integration strategies for small physician practices”
© 2012 American Medical Association. All rights reserved.
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Additional Public Resources• “Evaluating and Negotiating Emerging Payment
Options”– Introduction: “Evaluating and negotiating emerging
payment options;”– Chapter 1: “How to establish your baseline costs;”– Chapter 2: “Fee-for-service issues”– Chapter 3: “Pay-for-performance programs”– Chapter 4: “Capitation;”– Chapter 5: “Shared savings proposals;”– Chapter 6: “Bundled payments:” – Chapter 7: “Withholds and risk pools”
© 2012 American Medical Association. All rights reserved.
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Additional Public Resources– Chapter 8: “Risk adjustment”– Chapter 9: “Stop-loss insurance”– Chapter 10: “Working with actuaries”– Chapter 11: “Negotiating the deal”– Chapter 12: “Joint contracting/Collective bargaining”– Chapter 13: “Ethical implications of financial
incentives in managed care contracts”– Chapter 14: “Evolving compensation methodologies
for employed physicians in an era of changing clinical practice, reimbursement, and health reform”
© 2012 American Medical Association. All rights reserved.
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Additional Public Resources
www.ama-assn.org/go/aco
www.ama-assn.org/go/payment
© 2012 American Medical Association. All rights reserved.
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