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Health Care Risk Sharing, Integration & Accountable Care – Part 11

RISK SHARING, INTEGRATION AND ACCOUNTABLE CARE—BASIC CONTRACTING CONSIDERATIONS FOR PROVIDERS

Basic Extra-Contracting and Pre-Contracting Considerations: Providers must review the MCO, the network plan and/or the contractual clauses or venture terms underlying same, for answers to the following questions: (a) What are enrollment and disenrollment through the MCO, (b) what other providers are under arrangement with the plan and MCO, (c) how long do claims take to clear under the plan and MCO, (d) who owns the network, who controls utilization/authorization for services through the MCO/plan, (e) whether the plan and MCO is up to date with all state and federal filings, (f) whether the plan and MCO maintain good relations with regulators, and (g) the media and/or general public’s perception of the plan or MCO.  Pre-negotiation, provider must objectively assess their strengths and weaknesses, market competition, and their best, worst and acceptable contractual arrangements.  Success should be measured through the consummation of a deal which is mutually acceptable and beneficial to all parties.

This article is part of a series of articles on risk sharing, integration and accountable care.