Evaluating a Managed Care Contract: ACR Managed Care Committee Contract Evaluation Checklist
In an effort to assist American College of Radiology (ACR) and Radiology Business Management Association (RBMA) members in their interactions with private payers, the ACR Managed Care Committee and the RBMA Payor Relations Committee have developed an educational resource for evaluating contracts with insurers. The ACR MCC and RBMA Payor Relations Committee are pleased to provide the recently updated Contract Evaluation Tool (CET), which identifies important items to be considered and reviewed when evaluating and negotiating contracts.
When a contract is received from a private payer, all parties involved in the negotiation process should read the entire contract and all amendments of the contract completely. After doing so, some questions may arise. For example, you may ask yourself how to evaluate the reimbursement scale outlined in the contract. You may wonder if the group should agree to the "all products clause" listed in the contract, or the group may question if the timeframes in which claims must be submitted (as stated in the contract) are appropriate. The tool provides guidance on items such as these, which are usually included in typical contracts.
The CET includes a reference section on evaluating compensation. The section on compensation provides an Excel spreadsheet (developed by a radiology business manager) to help you predict how an insurer's payment proposal will likely impact your practice. The CET also includes a section on negotiation of contract specifics. In addition, the CET covers topics ranging from issues surrounding clean claims to negotiation of dispute resolution.
The CET will provide checkpoints to help you navigate the extensive process of contract negotiation. The tool describes some ideal situations to consider when evaluating contracts and outlines best-case scenarios. Individual practices should review the information contained in the tool and use that information as appropriate. It is important to note that the tool is not all-inclusive of issues or topics that arise during contract negotiation.
While the ACR MCC is please to provide this resource to ACR and RBMA members, the ACR maintains a firm position that ACR members must independently make contract-related decisions with private payers. To avoid legal liability, members should not use any recommendations offered in the tool in whole or in part to take collective action in negotiations with managed care organizations (MCO) or other third-party payers. Should you have any questions, comments or suggestions regarding this educational resource, please contact Katie Keysor at (800) 227-5463, ext. 4950. The CET is an evolving document, so please contact ACR staff for information on updates to the checklist.