Chapter 3: The Provider Network
Prior to beginning work on this assignment, review the following:
Why Removing Percent-Of-Charge Provisions in Managed Care Contracts Won’t Address Concerns About High Hospital ChargesDownload Why Removing Percent-Of-Charge Provisions in Managed Care Contracts Won’t Address Concerns About High Hospital Charges
Surprise Bills From Outpatient Providers: A National SurveyDownload Surprise Bills From Outpatient Providers: A National Survey
Evaluating Network Adequacy of Oral Health Services for Children on Medicaid in Arizona
There are several key elements required in a health care provider's contract with a managed care organization (MCO). A typical contract between an MCO and a physician contains definitions, terms, obligations, and other features of payer-provider agreements. Terms and clauses are not expected to be changed, while payment terms that can be renegotiated should be placed in appendices.
For this assignment, you are taking on the role of a provider relations manager at Allianta insurance company. You have an appointment with the practice administrator and physician leader at Ashford Medical Group (AMG), which is a multispecialty practice with 10 health care providers. Currently, AMG is not a participating provider at Allianta. The goal of this appointment is to recruit AMG to be an in-the-network provider at Allianta.
For this assignment, you must prepare a thorough PowerPoint presentation and record a screencast video of your PowerPoint presentation. You must use the Provider Contracts Presentation PowerPoint TemplateDownload Provider Contracts Presentation PowerPoint Template. Compose a transcript for your presentation in the Speaker Notes area.
Part 1: PowerPoint Presentation
The PowerPoint presentation must include the following:
Identify the justifications for health care providers to contract with Allianta.
Note: Reference Table 3.1 – Payer and Provider Reasons for Contracting in your textbook for information regarding the benefits of being an in-the-network provider.
Discuss the credentialing process.
Examine two important common clauses in the contract: no balance billing and nondiscrimination.
Analyze the importance of provider contracts in maintaining a provider network.
Explain network adequacy and its significance to health plan members.
