Managed care contracts. A guide for clinical case managers

When healthcare executives speak of managed care, they often use the term generically to refer to any arrangement with a healthcare payer other than traditional fee-for-service reimbursement. All too often, the "management" aspect is missing from managed care, resulting in an arrangement that could more aptly be described as "discounted care." This lack of clinical representation is unfortunate, since there are numerous issues that have an impact on clinical care, including choice of referral providers, noncoverage of certain procedures or treatments, and similar issues that may influence the patient's plan of care. Organizations that approach managed care as a system that blends the resources of management, finance, and clinicians, will enjoy the greatest potential for success. With their practical experience and insight into the administrative and clinical issues that may be encountered, nurse case managers will ultimately be responsible for managing the care of the contracted population. As case managers are the vital link among payers, providers, patients, and families, it is essential that the case manager understand managed care concepts, be conversant in the terminology of managed care, function as a member of the team responsible for evaluating contracts, and periodically review existing arrangements. This article presents an overview of the managed care contract development process, and provides tools to enable the nurse case manager to participate in the contracting process.