Law Note Series
Social Workers and Managed Care Contracts
by: Sherri L. Morgan, MSW,
JD and Carolyn Polowy, JD
Published: October 2000
Introduction: This law note was developed to aid clinical social workers who work in a managed care environment as independent practitioners in evaluating managed care agreements. For social workers new to managed care and for those who are assessing their provider status, it is helpful to have some understanding of the legal issues related to managed care contracts. Social workers involved in health policy development or legislative initiatives may also find the law note useful to identify particular aspects of managed care provider relationships in need of state or national legislative reforms.A three-stage process for analyzing managed care concerns is presented. First, social workers are urged to evaluate fully, in advance, the organizations with which they will be doing business. Second, analytical tools are provided for social workers to review critically the language presented in managed care provider agreements. Social workers are directed to seek out other resources where appropriate, including the advice of legal counsel. Third, social workers are presented with some general considerations if a formal means of redress is necessary to resolve conflicts between the parties to the contract. In addition, a glossary of managed care terms and acronyms is provided. Finally, model contract provisions are offered for those who are in a position to revise provider agreements to form the strongest fit between social workers' ethical obligations and managed care restrictions. In some instances, this law note suggests options for social workers that may be available in only a few, optimal circumstances; however, consideration of how managed care companies and social workers "should" act is instructive and anticipates the future direction of public and private standards in the managed care industry.
A dynamic flow of ideas and information moves between legislatures, government agencies, the courts, and private standard-setting organizations. As the "best practices" of the managed care industry emerge in any one of these bodies, new measures are quick to be adopted by others. Options available to a few social workers one year may be widespread within five. Social workers need to be informed about the general trends in the world of managed care to make wise decisions about what reforms to support, when to litigate, and when to wait patiently for the storm to pass.