Description
This unit provides a deep dive into the legal and regulatory environment governing payer-provider contracting in healthcare. It explores the statutory, contractual, and ethical frameworks that ensure fairness, transparency, and compliance in reimbursement agreements.
Learners will analyze how federal and state laws, including the Stark Law, Anti-Kickback Statute, HIPAA, and False Claims Act, shape contract formation and execution. The unit also examines CMS and state oversight mechanisms, highlighting how agencies enforce compliance and manage disputes.
Through real contract excerpts, learners will gain hands-on experience identifying risk clauses, evaluating compliance gaps, and applying checklists to assess contract integrity. By mastering the intersection of law, policy, and reimbursement, learners will be prepared to safeguard organizational compliance and negotiate legally sound agreements.
1. Identify Legal Foundations of Payer-Provider Agreements.
2. Explain legal clauses commonly required in government payer agreements.
3. Recognize the implications of “any-willing-provider” and anti-discrimination statutes.
4. Assess contracts for regulatory compliance (e.g., Stark Law, Anti-Kickback Statute).
5. Evaluate the role of CMS and state agencies in contract enforcement.
6. Analyze real contract excerpts for potential legal or compliance risks.
7. Apply a legal and transparency compliance checklist to ensure contract clauses align with federal and state requirements.
Upon completion of this unit, learners will be able to:
1. Interpret federal and state statutes governing payer-provider relationships.
2. Identify how legal clauses protect providers and payers while ensuring compliance.
3. Evaluate contract structures for transparency, anti-fraud safeguards, and equity.
4. Assess how agencies such as CMS, OIG, and state Medicaid offices enforce contract compliance.
5. Detect compliance risks within sample contracts and propose corrective actions.
6. Apply a compliance checklist to validate contract alignment with ethical and legal mandates.
7. Understand how anti-kickback and self-referral laws influence modern value-based care contracts.
Foundational understanding of Healthcare Reimbursement systems.
Basic knowledge of payer contracting principles and healthcare regulatory structures.
Familiarity with healthcare operations, compliance frameworks, or legal terminology is recommended but not required.
1. Healthcare Compliance Officers managing payer-provider contract adherence.
2. Contract Managers and Legal Counsel responsible for contract drafting and risk mitigation.
3. Health Administrators and Executives overseeing payer relations and organizational compliance.
4. Policy Analysts and Health Lawyers interpreting CMS, OIG, and state health statutes.
5. Revenue Cycle and Managed Care Professionals involved in the operational enforcement of contract terms.
6. Graduate students in health policy, public administration, or law preparing for roles in healthcare legal or regulatory fields.
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