Managed Care Contract Disputes

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Managed Care Contract Disputes

Managed Care Contract Disputes Lawyers

Representing Clients in California with Managed Care Disputes

When signing managed care contracts, it is important to remember that no contract is set in stone and you must always be prepared to negotiate. Before you sign a managed care contract, ask yourself the following questions:

  • Is the contract up to date? Make sure it reflects current state law regarding the operation of managed care organizations.
  • 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.
  • 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.
  • Does the contract provide a clear definition of "medical necessity"? Does it define "medical emergency"?
  • Does the contract include a "hold harmless" clause? This clause, which holds the provider, not the MCO, liable in malpractice actions, may be illegal.
  • What is the procedure for appealing care denials? As your patients' advocate, you need to know their rights and help them appeal denied care; you may even have a legal duty to do so.
  • What is the procedure for providing the MCO with patient records and data? 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.
  • Is there a due process provision for terminating providers from the panel? Make sure the contract specifically explains the appeal process and the possible bases for termination.
  • What are the payment rates for your services? Are they adequate to cover your costs and reasonable profit? Is it impossible to project your earnings under the provider agreement due to lack of specificity or data?
  • 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.
  • What are your rights if the MCO doesn't pay you for your services or doesn't pay you within a specified time?
  • What happens to your contract if the MCO merges or is acquired by another company? Does the contract become null and void? If so, within what period must you act to join the new MCO as a participating provider?

Note: Every case is different; the above questions are offered as suggestions only, and there may be other important issues to be considered in a particular instance. Please review our disclaimer regarding the information contained on this page.

At the Law Firm of Marvin Firestone, MD•JD, & Associates, LLP, we can help you to review your rights and obligations under a managed care contract and negotiate a contract that is in your best interests, before you sign on the dotted line.

Contact us to schedule a consultation with a California Health Care Attorney Today!

Contact our California health care attorneys today if you believe that a MCO has not fulfilled their obligations under your present contract. Fill out our online form or call (650) 212-4900 or toll free at 1-800-LAW-MDJD (1-800-529-6353) to learn about your options.

Our Northern California law firm has offices located in the San Francisco Bay Area and the Central Coast serving  clients throughout California.

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