2023 Managed Care Resource Kit
The Managed Care Legal Database is a resource identifying how state and federal statutes and regulations address many issues that may occur between private payers and physicians, such as prior authorization, credentialing, network adequacy, out-of-network payment, and contract termination. The Database also contains relevant AMA policy, issue briefs, advocacy resources, model legislation, and a State Laws Map.
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
