Cost:

Free for HFMA Members
Buy HFMA Membership to Attend

Audience:

Hospitals and Other Providers
Business Partners
Physicians and Other Practitioners

Career level:

Experienced Professional
Student
Early Careerist

Recommended for:

Payer Contracting
Claims
Managed Care
Physician Practice
Reimbursement

Delivery Method:

Self Study

Advance Preparation:

None

Prerequisites:

None

Course Availability:

18 Months

Blog | Contracting
Responses to the Business Group on Health's annual survey of its large employer members suggest employers are tired of waiting for providers and plans to figure out how to reduce healthcare cost.
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On Demand Webinar | Intermediate | Contracting
A medical center CEO will explain his role in facilitating contracting collaboration with medical staff, health plans, and with legal council for effective and efficient implementation in executing contracts. Learn about successful tools, s...
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Case Study | Contracting
Previous success in risk-based contracts will allow Atrius Health to thrive in its new global-risk arrangement with Blue Cross Blue Shield of Massachusetts, two of the provider’s leaders write.
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Trend | Contracting
A short description of payment methodologies offers context on the argument about whether fixed fees are preferable to percent-of-charge provisions.
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Trend | Contracting
Removing percent-of-charge provisions in favor of fixed fees would not remove the factors that drive price increases, nor would it reduce administrative hassles or decrease risk.
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Course | Intermediate | Contracting

Managed Care Contracting and Negotiating

Course | Intermediate | Contracting

Managed Care Contracting and Negotiating

Description

This course discusses criteria to use in evaluating the written contract between the provider and managed care organization, which defines the rights and obligations of the parties under the health plan/provider relationship. It also defines key contract terminology, provisions, and clauses and describes reimbursement levels and methodologies. It highlights general issues that commonly arise during the contract negotiation process and describes common negotiation strategies. It defines direct contracting and third-party contracting and points out the differences between them.

Estimated course completion time: 1 hour
After this program, you'll be able to..
  • Recognize a typical contract negotiation process
  • List some criteria that may be used to evaluate a contract
  • Identify other tools that can help optimize contract performance
  • Recognize the two types of carve-outs
  • Recognize the crucial differences between inpatient and outpatient services and how they relate to contracting
  • Recognize different approaches to contracting for ancillary services and which ones work best
  • Recognize several important contract terms, provisions, and clauses
  • Identify steps that can help prepare for negotiations
  • List some key negotiation strategies
  • Define direct contracting
  • Recognize the intent of direct contracting
  • Recognize how direct contracting often works in practice
  • Define third-party contracting
  • Define nondirected and silent PPOs
  • Differentiate between nondirected and silent PPOs
  • Identify some techniques that providers and health plans have established to avoid silent PPO activity

Related Courses | Contracting

On Demand Webinar | Intermediate | Contracting

Understanding the Semantics and Execution in Contract Negotiations

A medical center CEO will explain his role in facilitating contracting collaboration with medical staff, health plans, and with legal council for effective and efficient implementation in executing contracts. Learn about successful tools, strategies, and case studies for negotiating terms and identifying opportunities in health plan agreements and physician contracts.

Course | Advanced | Contracting

Contract Management

This course provides an introduction to managed care contracting. The purpose of a contract and its key components are described. The course explains criteria-based contracting. In addition, it describes elements to monitor to ensure contract compliance.


Estimated course completion time: 1 hour and 30 minutes

Course | Overview | Health Plan Payment and Reimbursement

Health Plans - An Overview

In this course we will address the basic billing rules for major health plans, including an overview of basic billing features and benefits, types of billing rules and minor claim payers and plans.


Estimated course completion time: 30 minutes

Course | Overview | Managed Care

Overview of Managed Care

This course provides an overview of the state of managed care today and discusses how and why it has evolved. It also identifies major initiatives that are currently affecting managed care and will continue to do so in the future, as the U.S. continues to implement the reforms associated with the passage of the Patient Protection and Accountable Care Act (ACA) in March 2010. The course offers a solid foundation of knowledge that will provide necessary context for the more detailed information presented in subsequent courses in this series.


Estimated course completion time: 45 minutes