Medicaid & SCHIP; Mental Health; Legal; Managed Care Contracting
The contracting process is one that health care professionals oftentimes find complex and confusing. Furthermore, studies of managed care service contracts between managed care organizations and health professionals who furnish mental illness and addiction disorder prevention and treatment services have found that these contracts often heavily favor the managed care organization by allowing the MCO broad latitude over a network professional's service responsibilities, the rate of payment for covered benefits and extensive discretion over treatment decision-making.
As an aid to its members, the American Medical Association (AMA) has drafted a "model" provider agreement that gives physicians in both individual and group practice a tool that can be utilized in the managed care contracting process. The AMA's contract is designed to help physicians understand and negotiate the contracts they sign. At the same time, the model contract is designed as a general medical services template. As a result, specialty providers such as mental health and addiction disorder treatment professionals and clinical providers may find that the model does not address certain critical contracting issues which exist as a function of their specialty practices.
In order to address the need for a "customized" model contract designed for use by health professionals and clinics furnishing mental health and addiction disorder treatment and prevention services, the Substance Abuse and Mental Health Services Administration (SAMHSA), funded the George Washington University Center for Health Services Research and Policy (CHSRP) to adapt the AMA model contract for use in this specialty area. Working in collaboration with a number of professional organizations including the National Association of Social Workers, the American Psychological Association, the National Association of Alcohol & Drug Abuse Counselors, the American Psychiatric Association, and the University of Maryland's Department of Behavioral and Community Health — CHSRP has adapted the AMA contract for use in the area of mental illness and addiction disorder network agreements.
Rosenbaum, S., Teitelbaum, J., Kamoie, B., & Mauery, D. R. (2002). Model managed care contract for health professionals and clinical providers of mental illness and addiction disorder treatment and prevention services. Washington, D.C.: Center for Health Services Research and Policy, Department of Health Policy, School of Public Health and Health Services, The George Washington University.