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目次

1. BASICS OF NEGOTIATING: Preparation; Formulation of Key Objectives and Deal Points; The Negotiating Team; Review of the Proposed Contract Terms; Agreement on Final Contract Language 2. ANTITRUST ISSUES IN MANAGED CARE CONTRACTING: Overview; Clinical Integration Issues for Provider Networks; Antitrust Regulatory Considerations Applicable to Pay for Performance (P4P) Arrangements; Messenger Model Contracting Concepts 3. KEY CONTRACT DEFINITIONS: Affiliates; Clean Claim; Covered Services; Effective Date; Emergency or Emergency Medical Condition; Medically Necessary; Member, Enrollee, or Beneficiary; Plan Sponsor or Payor; Products 4. PAYOR PROGRAMS AND POLICIES: UTILIZATION MANAGEMENT AND QUALITY ASSURANCE: Payor Programs and Policies; Utilization Management; Quality Assurance, Provider Credentialing, and Participation 5. RISK-BASED PAYMENT METHODS: Discounted Fee-for- Service; Per Diem Charge; Per Case Rates/Global Fees; Capitation; Percentage of Premium; Risk Pools; Pay for Performance; Government Risk-Based Payment Programs; Stark Law Considerations; Laws Regulating Physician Incentive Arrangements 6. TERM AND TERMINATION PROVISIONS: Term of the Agreement; Renewal Provisions; Termination Provisions; Compliance with Law and Termination; Rights and Obligations after Termination 7. INSURANCE REQUIREMENTS AND INDEMNIFICATION: Theories of Liability; Insurance Coverage Issues; Indemnification; Limitations of Liability; Tax Exemption Issues 8. OTHER CONTRACT PROVISIONS: Claims Submission; Payment; Records and Data Issues; Ownership of Medical Records and Authorization for Access; Subcontractor Relationships; Patient Relationships; Steerage; Assignment, Mergers and Acquisitions; Nondiscrimination; Sample Business Associate Agreement 9. DISPUTE RESOLUTION: Common Areas of Dispute; Internal Administrative Procedures; Nonbinding, Conciliatory Procedures; Binding, Adjudicatory Procedures; Procedures Required by Law 10. PROTECTING AGAINST INSOLVENCY: Termination Rights; Insolvency Insurance; Financial Reserve or Tangible Net Equity Requirements of Regulatory Agencies; Payment Delays and Losses Before Insolvency; Effective Contract Termination Provisions; Payor Risk Exposure in RBO Risk Withholds 11. GOVERNMENT PAYORS: Medicare & Medicaid Managed Programs; The State Children's Health Insurance Program Appendix A - Glossary of Health Plan Contracting Terms Appendix B - Table of Sample Clauses Appendix C - Physician Group Practice Provider Agreement Template with Commentary