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Law
Note Series
Social
Workers and Managed Care Contracts
by: Sherri L. Morgan, MSW,
JD and Carolyn Polowy, JD
Published: October 2000
Pages: 43
INTRODUCTION
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.
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