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[/vc_column_text][/vc_column][/vc_row][vc_row][vc_column][vc_column_text]A “Mulligan” is a not a managed care term. Take care not to fall into the following traps:
Several issues come into consideration when contracting with Managed Care plans and discount arrangements such as PPOs and other provider networks.
Take care not to fall into the following traps:
- All Products Contracts – requiring the same write-off requirements for HMO and non-HMO participants alike.
- Silent PPO Arrangements – requiring you to offer discounts other than the one they negotiated directly with you through purchase of access to your rates through other contracted plans selling you as consignment property
- Undisclosed fee schedules – fee schedules that refer to payment on the basis of some usual, reasonable and customary rate without stating a formula that can be audited to ensure that you have received the correct payment
- Undisclosed payment formulas (DRG Cost weights, etc.)
- Non-standard coding interpretations
- Non-standard billing codes
- Missing provisions for fair and equitable dispute resolution on matters related to price or value for new services and technology
- Missing provisions for the addition of new services or technology
- Limitations on types of providers that may be paid for specific services, (i.e, sleep study interpretations, etc.)
- Non-coverage for services related to specific disease and body parts, (i.e, TMJ, obesity, depression, family planning, feet, etc.)
- Requirements to give patients written notice in advance about non-covered services (non-covered means “non-contracted” = “no interference”)
- Mandated extension of discounts and write-offs on non-covered services (see above argument)
- Limitations on fee schedules and maximum allowable rates when coordinating benefits with other plans
- Timely payment statutes that don’t have a consequence if they pay you late.
- Non-payment for copies of records (only a handful of states protect plans for this)
Many providers establish some tracking method other than the aged trial balance and standards aging reports to manage denials. In your follow up file, you should have various form letters available for your use so that each case becomes classified into several categories that can be followed up in an organized fashion. A policy and procedure should be established and reviewed periodically to determine if it is still current or should be updated, in the face of new rules and regulations or contracted terms and conditions of payment. Consider developing a Payer Report Card.[/vc_column_text][/vc_column][/vc_row]
