Dear Association Executives - As discussed on today's call, attached and below please find "Possible Managed Care Contract Amendments to Seek During COVID-19" as prepared at our request by Adam Falcone, Partner at Feldesman Tucker Leifer Fidell LLP. Please let us know what additional information would be helpful.
Possible Managed Care Contract Amendments to Seek During COVID-19
- Shift Payment Methodology from FFS to Capitation. Some behavioral health providers receive a fixed amount (per-member, per-month) for the provider's scope of behavioral health services for a share of the managed care entities enrollees (i.e., for an attributed population). The fixed payment is made without regard to utilization of services, subject to a provider's capacity, though providers must continue to submit "encounter claims" to managed care organizations to document services that were furnished to enrollees.
- Shift Payment Methodology from FFS to Fixed Payment. Some behavioral health providers receive a fixed amount of payment to offer particular services, often subject to a capacity limit. This ensures that the provider receives a guaranteed revenue stream to maintain capacity to render the service even if actual utilization varies considerably. Providers must continue to submit "encounter claims" to managed care organizations to document services that were furnished to enrollees.
- Request Advance Payment. Some providers have negotiated a lump-sum advance during billing challenges or a change in reimbursement methodology. Although the advance is later reconciled against adjudicated claims (based on the underlying payment methodology), it can ensure sufficient funds remain available for operations during a time that may otherwise result in denials or delays. Once funds have been advanced, a behavioral health provider could use the time to develop and propose an alternative payment methodology than the one under the current contract.
President & CEO
National Council for Behavioral Health
Direct: (202) 684-3749
Director of Membership