Managed Care Contracting and Payer Relations Flashcards
6 cards from real CRCR practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Managed Care Contracting and Payer Relations flashcards as text
What does a 'fee schedule' in a managed care contract primarily define?
Answer: The maximum reimbursement a payer will pay for specific services rendered by a contracted provider
A fee schedule is the contractually agreed-upon reimbursement rate for each service or procedure code. It sets the ceiling on what the payer will pay the provider, regardless of the provider's billed charges.
A 'carve-out' provision in a managed care contract refers to:
Answer: A specific service or benefit that is excluded from the standard contract terms and governed by a separate agreement or rate
A carve-out removes certain services (e.g., behavioral health, pharmacy, or high-cost procedures) from the main contract and subjects them to different pricing or a separate sub-contractor arrangement.
What is the primary purpose of contract modeling in managed care contracting?
Answer: To project the financial impact of a proposed payer contract before it is signed
Contract modeling uses historical claims data and proposed rates to forecast expected reimbursement under a new or renegotiated contract, allowing providers to evaluate whether the terms are financially viable before signing.
A 'most favored nation' (MFN) clause in a managed care contract requires the provider to:
Answer: Offer the payer rates no higher than the lowest rate offered to any other payer
An MFN clause obligates the provider to give that payer its best (lowest) rate — if the provider later agrees to lower rates with another payer, the MFN payer automatically receives the same reduction.
When a provider renders a covered service to a plan member but the service is NOT on the contracted fee schedule, what is the most appropriate first step?
Answer: Refer to the contract language for an 'unlisted service' or 'gap fill' provision to determine the applicable rate
Most contracts include a gap-fill or unlisted-procedure clause specifying how to price services not explicitly listed in the fee schedule — often as a percentage of Medicare or billed charges. This must be followed before billing the patient or adjusting the account.
Which of the following best describes the role of a provider relations representative in managed care contracting?
Answer: Serving as the primary liaison between the provider organization and the payer to resolve contract disputes, credentialing issues, and reimbursement discrepancies
Provider relations reps facilitate the ongoing operational relationship between hospitals/physicians and health plans — handling contract interpretation questions, payment disputes, network status changes, and credentialing coordination.