Managed Care Contracts: What are you looking for?

By admin user

Published on October 6, 2019

In Blog Posts

In last month’s article, we talked about

diversification, and the importance of being well-positioned with all of the major insurer companies in your area. This month, we’ll take a quick look at “contract review.”


It seems obvious that reimbursement is important, but a surprising number of Providers accept the first contract they receive from a managed care organization, without evaluating the reimbursement schedule, or asking for higher reimbursement. Remember that managed care plans and insurance companies will offer you the lowest reimbursement level possible. They are hoping that you’ll agree to what they present, without questioning or counter-proposing. Always ask for more! Even if you don’t get what you ask for, you can almost always improve your rates by at least 10-15%.


Be absolutely certain you read the language that defines requirements for Bill Submission. Some plans will require that bills be submitted in sixty (60) days or less, and though 60 days may seem like plenty of time, we know that backlogs occur. To protect yourself and your ability to collect on 100% of your bills, be certain that you extend the bill submission deadline as much as possible. Industry standards dictate that you should always have at least 90-95 days for bill submission. Second to your reimbursement schedule, the timely payment language is one of the most important portions of your managed care agreement. Ideally, you want the contract to stipulate that payment for clean claims must be made within 30 days for electronically filed claims, and 45 days for paper claims. Late claim payments should be paid at full billed charges, with interest and penalties.


Almost all managed care plans and insurers have different products; PPO, HMO, EPO, and others. Be certain you understand these different products, and make informed decisions about whether you elect to participate in some or all of those products. If the contract proposed excludes your participation from one or more of the products offered, be sure you understand those limitations as well.

If you see things in your contract language or reimbursement that concern you, give us a call and let’s talk about it!