Healthcare organizations in the United States are changing how they manage contracts and provide care. These changes come from new rules that move payments from paying for each service to paying based on the value of care. At the same time, providers face higher demands for documentation and following rules set by the government and insurance companies. Medical practice administrators, owners, and IT managers need to understand these changes and adjust their contract plans to keep their finances steady, follow the law, and provide good patient care in a complex system.<\/p>\n
In the past, many healthcare providers used fee-for-service (FFS) contracts. In this system, providers got paid for each test, service, or procedure they did. This system is simple but can encourage doing more services rather than better care. Now, payers and regulators are focusing more on value-based care (VBC) contracts. These pay providers based on how good the care is and how healthy patients get, not just on the number of services.<\/p>\n
Healthcare groups are working with contracts that include risk-sharing, bundled payments, and episodic care payments. These link payments to specific health results. For example, the Centers for Medicare & Medicaid Services (CMS) started the Enhancing Oncology Model (EOM) in July 2023. It is a national program that builds on past oncology models to focus on value-based care for cancer patients getting chemotherapy for breast, lung, and prostate cancer. EOM sets up payment based on performance and improves care coordination through services like 24\/7 doctor access and patient navigation.<\/p>\n
Healthcare administrators should prepare for changes like higher Monthly Enhanced Oncology Services (MEOS) payments\u2014from $70 to $110 per patient starting in 2025. This change helps pay oncology practices better for complete care that covers medical needs and social factors that affect health. EOM also pushes the use of certified Electronic Health Records (EHR) and electronic patient-reported outcomes (ePROs). These help improve documentation to meet quality and law requirements.<\/p>\n
With the move to value-based contracts, there are more detailed documentation and compliance needs. Providers must now keep detailed records of care to show value, avoid penalties from audits, and follow laws like the Stark Law, Anti-Kickback Statute, False Claims Act, and HIPAA.<\/p>\n
For example, payer contracts now often need clear proof of care coordination, patient involvement, and following clinical guidelines. Organizations moving to value-based care must create new policies that support fast, accurate, and standard documentation. Legal teams or outside lawyers often check for risks and help reduce problems with non-compliance, fraud, or denied payments.<\/p>\n
Lawyers with healthcare experience help providers negotiate these tough contracts and align them with their goals. They also help with compliance strategies when reviewing managed care contracts and other payer agreements. This legal help keeps practices following the rules and protects them from audits and payment issues.<\/p>\n
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