AHLA Health Plans Contracting Handbook: A Guide for Payers and Providers (Non-Members)

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7th Edition
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ISBN: 9781632805423
Publisher: AHLA
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Book Edition: 7E+CDB

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The Health Plans Contracting Handbook, Seventh Edition from AHLA traces the managed care contracting process from preparing to negotiate the contract, to formation and implementation, to termination issues. It identifies key questions typically encountered in preparing such agreements with a perspective that incorporates the current environmental challenges confronting managed care organizations, including the impact that healthcare reform issues will have on Provider-Payer relations. The Handbook considers the interests of Payers alongside those of providers and juxtaposes sample Provider-Friendly and Payer-Friendly language in order to help frame the negotiation and documentation of the parties' competing interests. It also offers separate chapters on Medicare and Medicaid managed care contracting in recognition of the growing significance that governmental Payers will have in years to come. Each chapter finishes with a bullet-point checklist of key considerations and a list of other useful resources, including both print and web-based sources. A collection of sample clauses is provided on the enclosed CD-ROM, so you can draft and customize your clients' contracts more efficiently.

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Published October, 2015.

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Table of Contents


1     Introduction: Basics of Contracting and Negotiating

2     Accountability and Collaboration—The New Paradigm in Payer-Provider Relationships

3     Antitrust Issues in Payer/Provider Contracting

4     Key Contract Definitions

5     Payer Programs and Policies: Utilization Management and Quality Assurance

6     Payment Methodologies, Including Risk-Based Payment

7     Term and Termination Provisions

8     Insurance Requirements and Indemnification

9     Other Material Contract Provisions

10   Dispute Resolution

11   Protecting Against Insolvency

12   Medicare Managed Care Contracting

13   Medicaid Managed Care

Appendix A   Glossary of Health Plan Contracting Terms

Appendix B   Table of Sample Clauses

Appendix C   Physician Group Practice Provider Agreement Template with Commentary