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Healthy Contracts - 72 Discussion Papers.
https://www.mentorresearch.org/healthy-contracts-categorized
Definitions
Definitions For Alternative and Value-Based Payment Contracts.
https://www.mentorresearch.org/healthy-contracts-bill-definitions
Plain Understandable and Transparent Contract Language
Contracts and Policies Shall be Written in Plain, Understandable Language.
The discussion paper emphasizes the importance of writing contracts and policies in plain, understandable language, particularly in mental and behavioral health services. This improves comprehension, reduces errors, enhances trust, supports informed consent, and ensures accessibility for diverse populations. Plain language fosters transparency, increases patient engagement, and helps health plans comply with legal standards, such as the Plain Writing Act. It also streamlines processes, leading to cost efficiency and better health outcomes.
https://www.mentorresearch.org/contracts-and-policies-shall-be-written-plain-languageAsymmetrical Information - Mitigating Adverse Effects.
The discussion paper titled Mitigating Asymmetrical Information explores how imbalances in information between health plans and providers can lead to issues in contract negotiations and service delivery. It emphasizes the importance of transparency, clear communication, and standardized definitions in health plan contracts to ensure fairness. The paper suggests strategies for reducing asymmetry, such as the use of plain language contracts, independent audits, and enhanced oversight mechanisms, to protect both providers and patients from unfair practices and ensure integrity in healthcare contracting.
https://www.mentorresearch.org/mitigating-asymmetrical-information
Good Faith and Fair Dealing
Good Faith and Fair Dealing in Healthcare Contracting for Fee-For-Service, Alternative and Value-Based Payment Models
The discussion on "Good Faith and Fair Dealing" highlights the necessity for integrity, honesty, and fairness in healthcare contracts, especially as Oregon moves toward value-based payment models. It advocates for transparency, accountability, and collaboration in healthcare contracting, ensuring mutual benefit and protection from corporate profiteering. The document emphasizes contract enforceability, patient-centered outcomes, and the importance of clear language to safeguard stakeholders, including providers, taxpayers, and patients.
https://www.mentorresearch.org/good-faith-and-fair-dealingSigns of Bad Faith in Value-Based Payment Contracts for Mental and Behavioral Health Services Offered by Healthplans
The discussion outlines key signs of bad faith in value-based payment contracts. These include ambiguous terms, skewed risk-sharing, unrealistic performance targets, lack of support, delayed payments, and poor communication. It highlights the importance of transparency, fair risk distribution, and achievable goals to ensure providers are not exploited. Providers are encouraged to negotiate clear terms and assess contracts for hidden risks and unfair conditions.
https://www.mentorresearch.org/signs-of-a-bad-faith-valuebased-payment-contractUnethical Tactics in Pay-for-Performance: How Health Plans Manipulate Provider Contracts in Value-Based Care.
The discussion paper outlines tactics some health plans use to manipulate pay-for-performance models to their advantage, often at the expense of providers and patients. It highlights issues such as shifting performance benchmarks, withholding critical information, and manipulating data to justify reduced payments. The paper emphasizes the need for stronger regulatory oversight, clearer contract terms, and ethical safeguards to prevent these practices and ensure that pay-for-performance models genuinely incentivize quality care.
https://www.mentorresearch.org/unethical-health0plan-tactics-in-pay-for-performance
Risk of Contract Failure
Healthplan Unethical Behavior, Bad Faith and Fraud.
The discussion paper outlines how health plans engage in fraudulent practices, such as concealing contract terms, manipulating performance metrics, and delaying payments, all to exploit mental health providers financially. It stresses the need for stronger oversight, transparent policies, and independent audits to prevent fraud and protect providers. It also highlights the role of Certified Internal Auditors in detecting such fraud, ensuring compliance, and maintaining integrity within healthcare systems.
https://www.mentorresearch.org/preventing-healthplan-and-payer-fraud
Importance of Clear and Accountable Contract Requirements for Value-Based Payment Contracts.
This discussion emphasizes the need for clear and accountable language in value-based payment contracts within mental and behavioral health services. It highlights the importance of transparency, consistency, fairness, and compliance to ensure stakeholders understand contract terms. Clear contracts enhance trust, reduce disputes, promote equitable practices, and ensure accountability through regular auditing and continuous improvement.
https://www.mentorresearch.org/importance-of-clearly-written-and-accountable-contractsContract “Gaming”: Reasons Why Value-Based Contracts Can Fail.
The discussion on "Contract Gaming" explores how health plans and providers exploit value-based payment contracts for financial gain. Health plans may manipulate metrics, enroll healthier patients, or impose stringent terms to limit payouts. Providers might engage in practices like cherry-picking or upcoding due to financial pressures or unrealistic contract demands. These behaviors distort performance data, erode trust, and undermine the goals of value-based care. Legislative reforms and transparent, fair contract practices are suggested to combat these issues.
https://www.mentorresearch.org/contract-gaming-reasons-why-value-based-contracts-will-fail
Whistleblower Protections
Why do Providers Avoid Conflicts with Healthplans?
The discussion explores why healthcare providers avoid conflicts with health plans. Key reasons include low reimbursement rates, high administrative burdens, restrictive policies, and quality of care concerns. Providers may covertly limit the number of patients from certain health plans to maintain financial viability, professional autonomy, and patient care quality. Fear of retaliation, legal consequences, and emotional stress also deter providers from confronting health plans directly.
https://www.mentorresearch.org/why-do-provider-avoid-conflicts-with-healthplans
Reporting and Ethics Point Portals
Empowering Providers to Report Suspicious, Unethical, and Illegal Behaviors: A Critical Approach for Healthcare Integrity.
This discussion paper emphasizes the importance of empowering healthcare providers to report unethical, suspicious, or illegal behaviors. It supports the creation of an ethics point portal with whistleblower protections, promoting accountability and transparency. The paper highlights the benefits of such systems, like safeguarding patient care and reducing legal risks, while addressing challenges such as over-reporting, misuse, and administrative burdens. By fostering a culture of ethical responsibility, the system ensures that both patient and provider interests are protected in healthcare settings.
https://www.mentorresearch.org/empowering-providers-to-report-suspicious-unethical-and-illegal-behaviorsReporting Unethical, Suspicious or Potentially Illegal Healthcare Contracting Behavior.
The discussion paper focuses on identifying and reporting suspicious, unethical, and potentially illegal behaviors in healthcare contracting. It highlights key concerns such as unilateral contract changes, lack of transparency, downside risk manipulation, and predatory contracting. These practices often lead to disputes, ethical violations, or legal claims, including fraud and misrepresentation. The paper underscores the importance of clear reporting mechanisms and whistleblower protections to ensure transparency and accountability in healthcare agreements.
https://www.mentorresearch.org/reporting-unethical-suspicious-and-potentially-illegal-behaviorEthics Point Portal: Definition and Benefits for Value-Based Contracts in Mental and Behavioral Health Services.
The discussion emphasizes the importance of posting audit results and mitigation strategies on a public electronic platform for health plans in mental and behavioral health. This promotes transparency, fosters trust, supports informed decision-making, encourages continuous improvement, and helps mitigate legal risks. It also enhances the quality of care by reinforcing ethical practices and promoting collaboration among stakeholders, leading to better outcomes in health services.
https://www.mentorresearch.org/ethics-point-portal-definition-and-benefitsThe Results of Audits and Mitigation Options Should be Posted on a Public Electronic Platform Webpage.
The concept of posting audit results and mitigation options on a public electronic platform is meant to enhance accountability in healthcare contracting. By making this information publicly accessible, health plans can build trust with both providers and patients, encouraging ethical practices and transparent operations. This transparency also ensures that any issues identified during audits are clearly addressed and corrected, ultimately leading to better patient care and improved health outcomes. It aligns with efforts to foster openness and collaboration across the healthcare system.
https://www.mentorresearch.org/posted-on-a-public-electronic-platform-webpageThe Independent Certified Internal Auditor Shall Audit Reports Registered in the Online Ethics Point Portal that Pertain to Mental and Behavioral Health Service Contracts and Policies.
This discussion paper emphasizes the role of a Certified Internal Auditor in reviewing reports submitted through the Ethics Point portal in healthcare organizations. This process ensures transparency, identifies and corrects unethical or illegal practices, and maintains compliance with regulations. By having an independent auditor conduct these reviews, health plans can foster trust, uphold ethical standards, and create a system of accountability that mitigates risks and prevents conflicts of interest.
https://www.mentorresearch.org/auditor-shall-audit-reports-registered
The Role of an Ombudsman
This discussion paper explores the function of an ombudsman as a neutral third party responsible for addressing complaints, mediating disputes, and promoting fairness within organizations. The primary role of an ombudsman is to provide informal conflict resolution, facilitate dialogue, and recommend non-binding solutions, particularly in areas such as government, healthcare, and corporate governance. The paper emphasizes the ombudsman’s neutrality, confidentiality, and lack of legal enforcement power, making them unsuitable for addressing serious legal matters such as fraud or antitrust violations. It highlights that while ombudsmen can mediate and investigate complaints, they do not have the authority to impose penalties or pursue legal action, underscoring the importance of referring complex legal issues to appropriate regulatory or legal authorities.
https://www.mentorresearch.org/the-role-of-an-ombudsmanThe Dangers of Using an Ombudsman for Fraud and Antitrust Violations: Undermining Accountability and the Legal Process.
This discussion paper warns against the use of an ombudsman in addressing serious legal matters like fraud and antitrust violations. It explains that while ombudsmen serve as neutral mediators in resolving disputes, they lack the legal expertise and enforcement authority needed for investigating or prosecuting criminal or civil violations. Relying on an ombudsman for these serious issues risks undermining accountability, as key evidence might be mishandled or lost, and wrongdoers could avoid legal consequences. The paper argues that such cases should be handled by qualified legal authorities to ensure transparency, proper legal procedures, and public accountability.
https://www.mentorresearch.org/the-danger-of-using-an-ombudsman-in-cases-of-fraud-and-violations-for-antitrust
Independent Certified Internal Auditors
Ethics-Point Portals Overseen by Independent Certified Internal Auditors (CIA): A Resource to Serve Stakeholders and the Public.
This discussion emphasizes the role of Certified Internal Auditors (CIAs) overseeing Ethics Point portals in healthcare. Their independent audits ensure objectivity, transparency, compliance with regulations, and ethical practices in mental and behavioral health services. By enhancing trust, mitigating risks, and promoting continuous improvement, CIAs help resolve reported issues effectively, supporting a culture of accountability and high-quality care.
https://www.mentorresearch.org/ethics-point-portals-overseen-by-independent-certified-internal-auditorA Case for the Value and Importance of Independent Internal Auditors in Contracting for Fee-For-Service, Alternative, and Value-Based Mental and Behavioral Health Services.
The discussion highlights the value of independent Certified Internal Auditors (CIAs) in healthcare contracting, particularly for ensuring transparency, compliance, and objectivity. Independent CIAs are vital in reviewing internal processes, protecting stakeholders, and maintaining trust in mental and behavioral health services. Their oversight supports the integrity of value-based and fee-for-service contracts by auditing financial practices, ensuring ethical operations, and reducing conflicts of interest.
https://www.mentorresearch.org/value-and-importance-of-independent-internal-auditors
DISCLAIMER and PURPOSE: This discussion document is intended for training, education, and or research purposes only. The information contained herein is based on the data and perspectives available at the time of writing. It is subject to revision as new information and viewpoints emerge.
For more information see: https://www.mentorresearch.org/disclaimer-and-purpose