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Payer Contract Negotiations and Payment Resources

 

​A viable pediatric practice needs to be able to analyze and effectively negotiate healthcare payer contracts. Have a clear understanding of business principles, current market trends, and the cost of delivering quality healthcare. The AAP has provided resources below.

Guiding Principles for Managed Care Arrangements for the Health Care of Newborns, Infants, Children, Adolescents, and Young Adults
Managed care plan can minimize patient under- and overutilization of services, as well as enhance quality of care. The AAP urges the use of the key principles outlined in this policy statement in designing and implementing managed care programs. 

Bright Futures Payment Information 
The Patient Protection and Affordable Care Act (ACA) recognized the importance of preventive care for children without cost-sharing. 

Essential Contract Language for Medical Necessity in Children
The relationship established between health care providers and health plans should promote arrangements that are beneficial to all who are affected by these contractual arrangements.

How to Respond to a Payer Audit
In an effort to control costs, carrier claims processing and Special Investigative Units are conducting audits of claims to prevent improper payments and overpayments.

In addition to the steps outlined in the article, see Checklist to Prepare Your Office for An Audit Site Visit. for additional information.

Fraud, Abuse, and Compliance                 
What to do when an auditor knocks on your practice's door                                                                        

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