SNHU Physician Hospital Organizations Contract Paper

User Generated

GPFtz

Health Medical

Southern New Hampshire University

Description

  • Select one managed care organization and create a two-page hospital inpatient managed care contract. The contract can be written from the perspective of the MCO.
  • Your contract should address information from a minimum of 6 of the following areas:
    • Reimbursement levels and parameters
    • Administrative cost criteria
    • Provider cost and responsibility
    • Volume
    • Risk assumption criteria
    • Claims payments and eligibility determination
    • Eligibility determination and prior authorization
    • Dispute resolution
    • Contract Termination
  • In a seperate paragraph, provide a detailed explanation stating how each of your selected criteria should be written to protect the MCO.

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Explanation & Answer

Please view explanation and answer below.

1

Physician-Hospital Organizations

Students Name
Affiliate Institution
Instructor's name
Course number
Date

2

Physician-Hospital Organizations
Reimbursement Levels and Parameters
The payment system is essential in the managed care contract for the supplier. The
Agreement should specify when, how and what will be paid to the contractor. Employees from
the supplier should be familiar with responding to an offer and processing processes. Is it
possible for the MCO to adjust the fee structure or fee for service rate at any time? A supplier
must contemplate a capitation agreement only when a foreseeable volume of subscribers during
the Agreement's relevant term. One option to restrict the supplier's risk assumptions is to
mandate "stop-loss" insurance to protect the providers from unanticipated losses resulting from
the fee for service payment. The providers should be aware of the actuary’s data, other facts, and
inferences to determine the capitation rate (Azni et al.,2021). No operator should contemplate
joining a group with other suppliers they do not believe would effectively manage their
consumption.
Administrative Cost Criteria
Insurance providers have stated that admin expenses associated with benefits
coordination account for around 12percent of program premiums on aggregate. Per Medicare, the
expenditures for public payers i...


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