The article outlines a four-step process for providers to effectively identify, capture, and bill for these exclusions, emphasizing the importance of contract negotiation, team communication, infrastructure like case managers and technology, and accurate billing practices to ensure full financial recovery in a complex reimbursement landscape.
There’s a key question more providers need to know the answer to: What is a contract exclusion?
A contract exclusion details the medications and treatments that are not included in the levels of a managed care contract. Are exclusions a good thing or bad thing?
That depends on us, the provider. If we identify and capture these exclusions and bill the health plan for them, then exclusions are great. If we are unaware of the exclusions or are unable to identify them, then they’re not so great.
Mix, S. (2023, December 18). An insider’s guide to managed care contract exclusions. McKnight’s Long-Term Care News. https://www.mcknights.com/blogs/guest-columns/an-insiders-guide-to-managed-care-contract-exclusions/
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