A Managed Care Resource: Navigating Legal Complexities in Healthcare

Introduction

In the ever-evolving landscape of healthcare, the intersection of legal statutes, regulations, and medical practices is becoming increasingly complex. Managed Care Organizations (MCOs), physicians, and healthcare professionals face a myriad of challenges ranging from prior authorization to network adequacy. Addressing these challenges requires not only medical expertise but also a thorough understanding of the legal framework governing these interactions. This is where the Managed Care Legal Database comes into play, offering a comprehensive resource for navigating these complexities.

Key Features of the Managed Care Legal Database

1. State and Federal Statutes and Regulations: The database provides an exhaustive list of state and federal statutes and regulations, giving users an understanding of the legal landscape surrounding managed care. This includes information on prior authorization processes, credentialing of healthcare providers, and guidelines for network adequacy.

2. Physician-Payer Interactions: One of the core aspects of the database is its focus on the relationship between private payers and physicians. It sheds light on legal considerations in contract termination, out-of-network payment disputes, and other areas of potential conflict.

3. AMA Policy and Issue Briefs: The inclusion of American Medical Association (AMA) policy statements and issue briefs offers insights into the stance of one of the leading medical organizations on various managed care issues. This is particularly valuable for understanding the broader implications of these legalities on medical practice.

4. Advocacy Resources: Recognizing the need for active engagement in shaping healthcare policies, the database provides advocacy resources. These tools are essential for healthcare professionals who are looking to influence policy-making in managed care.

5. Model Legislation: For those involved in legislative processes, the database offers model legislation. This feature is crucial for drafting new laws or amending existing ones in line with best practices in managed care.

6. State Laws Map: A unique feature of the database is the State Laws Map, which provides a visual representation of how different states approach managed care regulations. This is particularly useful for practitioners operating in multiple states or for those who need to understand regional differences in healthcare law.

Conclusion

The Managed Care Legal Database stands as a pivotal resource for healthcare professionals, offering a blend of legal information, policy insights, and practical tools. Its comprehensive coverage of the legal aspects of managed care equips users with the knowledge necessary to navigate this complex field effectively. Whether it's for understanding specific regulations, engaging in policy advocacy, or simply staying informed about the legalities of healthcare, this database serves as an invaluable tool for professionals committed to delivering value-based care.

Payment Issues

• Fee Schedules

• Fee Schedules-Med. Adv.

• Liability-insurer shifting to physician

• Liability-insurer shifting to physician-Med. Adv.

• Most Favored Nation

• Overpayments / Recoupments

• Payment Edits

• Payment Rules

• Prohibited financial incentives

• Prohibited financial incentives-Med. Adv.

• Risk—Physicians Taking

• Risk-Physicians Taking-Med. Adv.

Network Issues

• Continuity of Care Post-Contract

• Continuity of Care Post-Contract-Fed. Exchange Reg.

• Credentialing-Deadlines

• Credentialing-Due Process-Denial of Contract

• Credentialing-Patient Demographics

• Credentialing-Payment Issues

• Directories

• Directories-Med. Adv.

• Directories-Fed. Exchange Reg.

• Network Adequacy

• Network Adequacy-Fed. Exchange Reg.

• Network Adequacy-Med. Adv.

• OON-Payment Issues

• Participation in Products, Plans, or Networks

• Profiling

• Rental Networks

Contract Changes / Disputes

• Amendments

• Amendments-Med. Adv.

• Anti-gag clause

• Anti-gag clause-Med. Adv.

• Anti-retaliation

• Anti-retaliation-Med. Adv.

• Restrictive Covenants

• Termination

• Termination-Med. Adv.

• Termination-Due Process

• Termination-Due Process-Med. Adv.

Coverage / Utilization Review

• Medical Necessity-Definition

• State Medical Necessity Decisions-Deadlines

• State Medical Necessity Appeals-Deadlines

• ERISA-Med. Nec. Decisions-Deadlines

• ERISA-Med. Nec. Appeals-Deadlines

• Preemption-ERISA

• Med. Adv.-Med. Nec. Decisions-Deadlines

• Med. Adv.-Med. Nec. Appeals-Deadlines

• Preemption-Medicare Advantage

• Retroactive Denial

• Step Therapy Override

• U.R. Criteria

Claims Processing

• Claims Filing Deadlines

• Prompt Payment Deadlines

• Prompt Payment Deadlines-Med. Adv.