Professional Learning Center

Legal and Ethical Issues In Managed Care: Outilne

I. Introduction to Managed Care Contracting

This outline provides an introduction to the managed care provider contract and steps for providers to take to prepare for the contracting process. It underscores the importance of provider's preparation for the contracting process. It also presents a general outline to the provider contract. Finally, the outline presents selected provisions of provider contracts and identifies important points and issues for providers to consider.

II. Medical Necessity and Parity

This outline provides an overview to two topics, which are important in the managed care environment: The concept of medical necessity; and mental health parity. In Part I, the outline examines medical necessity. The outline presents alternative definitions to medical necessity and discusses consequences to the provider. Material is also presented on efforts in New York State to pass a statutory definition to "medical necessity." Part II of the outline looks at the issues around mental health parity. Both federal law and a New York State Assembly bill are presented for review and consideration. Medical necessity determinations become the central way of limiting client access to services.

III. Confidentiality, communication and the Client

This outline examines the central issue of confidentiality in behavioral health care services. After identifying the tension between the need for privacy and the need for information in a computer driven society, the outline will focus on concerns of confidentiality in a managed care environment. Finally, the outline will examine the recently released draft federal regulations on standards for privacy of individually identifiable health information, with special attention to the behavioral health field.

IV. Utilization Review and Resource Management: the Appeals and Grievance Process in Managed Care

This outline examines the utilization review and resource management processes in managed care and will focus on appeals procedures. After defining important terms, the outline will present the New York State's new external review law. The material will then present some possible effects of the new law.

V. Risk Sharing and Payment Mechanisms in Managed Care

This outline presents the various payment mechanisms utilized by managed care programs to share risk with providers. After describing the development of risk sharing systems, the outline describes the different mechanisms used in risk sharing, and identifies the conflict of interest between providers and payers inherent in risk sharing in behavioral health care.

VI. Ethics and Risk Management in Managed Care

This outline focuses on the important legal and ethical issues that arise in managed care. After examining the central role of informed consent and how it is changing in managed care, the outline will turn to the ethical problems in various payment arrangements. Finally, the focus will turn to the concept of confidentiality and its changing meaning.

VII. Federal and State Laws Which Impact on Providers

This outline reviews the various federal and state laws which have a significant impact on providers and consumers in managed care. It will focus on the Federal Employee Retirement Income Security Act of 1974 (ERISA), its impact on managed care, and on selected provisions of New York Public Health and Insurance Laws.

VIII. Patient Bill of Rights: Senate & House Bills and New York State Law

This outline will compare the two proposals for Patients' Bill of Rights recently under consideration in Congress with existing managed care laws in New York State. After a brief introduction it will focus on comparing the two congressional bills with the current situation in New York in three major areas: 1. Access To Health Care Providers, 2. Utilization Review (internal and external appeals), and 3. Health Plan Liability. Sub-topics will be limited to matters of general interest to behavioral health care providers and issues discussed during the eight seminars in the Managed Care Readiness Series.

Back to the information on the Summary Book.