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Managed Care Contracts: A Case Study

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It is clear that the risk assumption via capitation demands complex business skills for which many practitioners are ill prepared. That also suggests that that loose partnerships of the medical practitioners for reasons of collective contracting, instead of clinical management such as traditional medical groups, has been unsuccessful. If the managed care organizations are to regain their mastery over the health care system, such network models as independent practice associations ought to evolve into stronger medical group institutions that not only accept risk but which can also assume the financial as well as the clinical accountability for administering and managing the care of the population to which they provide their services (Kongstvedt, 2012).
The following is a checklist that will be utilized as a tool when organizations review the UMUC Medical Center's Managed Care Contracts
• What are the product lines of the MCO?
• What medical services are covered by the contract? Include any service …show more content…
• Obtain a sample format for reporting requirements
• Understand the credentialing standards. Determine if there are any requirements your providers do not meet.
• Obtain and understand the provider liabilities requirements.
• Review the provider’s conflict resolution process. Is there an arbitration process?
• Obtain and understanding the claim process including timeframes for submission of claims and payments.
• Obtain a contract address and telephone list of pertinent MCO staff including provider relations, technical contract and claims processing.
• Understand the contract termination process including time frames
Terms and Conditions within the contract
In reviewing the Managed Care contract for UMUCMC it is important to review some important terms and conditions within the contract and further explain and review how they fit into the provisions set out by

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