Healthy Contracts - Discussion Papers

Below is a library of discussion papers intended for training and education of Providers, Healthplan managers, legislators, attorneys and regulators. The library is organized by topic.

Definitions

Definitions For Healthy Contract Design.
https://www.mentorresearch.org/healthy-contracts-bill-definitions

Transforming Fee-for-Service to Value-Based Payment Contracts

Transition from Fee-for-Service Step-Wise to Alternative Payment Contracts and then Value-Based Payment Contracts: The Good and the Bad.
The paper outlines a framework for transitioning traditional fee-for-service psychotherapy models to value-based payment contracts. It discusses the key principles of value-based care, including outcome measurement, quality improvement, and the alignment of financial incentives. The content highlights challenges and strategies for integrating these principles into practice, emphasizing the importance of adapting clinical workflows and ensuring fair reimbursement structures. The discussion also addresses potential pitfalls and offers recommendations for successful implementation.
https://www.mentorresearch.org/transforming-feeforservice-psychotherapy-to-valuebased-payment-contract
Transforming Mental Health Services From Fee-for-Service to Value-Based Contracts: A Closer Look.
The paper examines the complexities of transforming mental health services by analyzing current barriers and proposing actionable strategies for improvement. It contrasts traditional care models with modern approaches, emphasizing the need for integrated care, evidence-based practices, and enhanced provider collaboration. Key points include addressing service fragmentation, optimizing care coordination, and promoting patient-centered models. The content provides insights on how to achieve meaningful reform in mental health delivery systems.
https://www.mentorresearch.org/transforming-mental-health-services-a-closer-look
Behavioral Health Quality Framework: A Roadmap For Using Measurement To Promote Joint Accountability and Whole-Person Care.
This paper outlines a behavioral health quality framework aimed at improving care for individuals with mental health and substance use conditions. It focuses on enhancing measurement, care coordination, and health outcomes through better integration of physical and behavioral health, promoting person-centered care, and addressing social determinants of health. The paper also highlights the importance of data systems, standardized measures, and value-based care models to support these efforts.
https://www.ncqa.org/wp-content/uploads/2021/07/20210701_Behavioral_Health_Quality_Framework_NCQA_White_Paper.pdf

Measurement and Value-based Payment Contracting

Measurement-Based Care: Enhancing and Undermining Mental Health Treatment Values.
Discussion paper describes the concepts of measurement-based and outcome-informed care, focusing on how these approaches use standardized tools to track patient progress and inform treatment decisions. It outlines the benefits of incorporating structured assessments, such as improved clinical outcomes and more personalized care. The content contrasts these methods with traditional clinical judgment and discusses practical challenges in implementation, including provider training and integrating data into clinical workflows.
https://www.mentorresearch.org/what-is-measurement-based-and-out-come-informed-care
Outcome Informed Care And Measurement-Based Care Adoption - Challenges in Oregon.
This discussion addresses the challenges associated with adopting measurement-based care in mental health settings. It examines common barriers such as provider resistance, lack of standardized measures, and integration issues with electronic health records. The content highlights the need for training, data management support, and leadership engagement to ensure successful implementation. The discussion also explores how overcoming these obstacles can lead to better clinical outcomes and a more structured approach to treatment planning.
https://www.imhpa.org/measurement-based-care-adoption-challenges
Patient Reported Outcomes & Performance Measures (PROM-PM).
This discussion explores the role of patient-reported outcomes and progress measures in enhancing psychotherapy services. It outlines how these tools capture patient perspectives on treatment effectiveness and track changes over time, providing valuable insights for clinicians. The discussion contrasts these measures with traditional clinician assessments and emphasizes their impact on treatment planning, therapeutic alliance, and overall care quality. Practical considerations for implementation, including selecting appropriate tools and integrating feedback into clinical practice, are also discussed.
https://www.mentorresearch.org/patient-reported-outcomes-progress-measures

Contract Negotiation Issues

Unfair Financial Risks in Healthcare: Challenges for Providers in Public and Private Contracts.
The paper examines unfair financial risks imposed on healthcare providers through contracting practices. It discusses how certain value-based payment models and contract terms shift excessive financial burdens onto providers, jeopardizing their financial stability. The analysis highlights the impact of these risks on small and independent practices, emphasizing the need for equitable contract structures that balance financial accountability with sustainable operations.
https://www.mentorresearch.org/unfair-financial-risks-in-healthcare

Asymmetrical Information - Mitigating Adverse Effects.
This discussion examines strategies to mitigate asymmetrical information between health plans and providers in value-based care contracts. It discusses how unequal access to data and unclear contract terms can lead to imbalanced negotiations and poor alignment of incentives. The discussion outlines approaches such as transparency in performance metrics, clear definitions, and standardized reporting requirements to promote fairer contracting practices and improve trust between parties. Potential impacts on care quality and provider autonomy are also explored.
https://www.mentorresearch.org/mitigating-asymmetrical-information
Addressing Asymmetric Power Dynamics and Ethical Concerns in Health Plan Contracts.
This discussion paper addresses asymmetric power dynamics and ethical concerns in health plan contracts. It analyzes how imbalances in negotiation power can lead to unfair contract terms, impacting provider autonomy and patient care. The paper explores strategies to create more equitable contracting, such as incorporating standardized definitions, ethical oversight, and ensuring transparency in contract negotiations. It also highlights the importance of including safeguards to protect against coercive practices and unethical contracting behavior.
https://www.mentorresearch.org/addressing-asymmetric-power-dynamics-and-ethical-concerns-in-health-plan-contracts
Collaboration Agreements For Value-Based Payment Services and Contracts.
This article discusses the role of collaboration agreements in value-based payment contracting. It outlines how these agreements can help define shared responsibilities, financial arrangements, and performance expectations between providers and health plans. The article emphasizes the importance of clear communication, mutual trust, and alignment on care goals to support successful partnerships. Key considerations include structuring agreements to balance risk, ensuring compliance with regulatory requirements, and promoting long-term sustainability.
https://www.mentorresearch.org/collaboration-agreements-for-valuebased-payment-contracting
Medically Necessary and Reasonable Psychotherapy Services.
This paper examines the concepts of "medically necessary" and "reasonable" within the context of health plan policies and coverage decisions. It contrasts how different definitions and interpretations can lead to variability in service authorization and reimbursement, often causing confusion for both providers and patients. The paper discusses the impact of these terms on care access and outlines recommendations for clearer, standardized definitions to reduce ambiguity and ensure equitable treatment decisions.
https://www.mentorresearch.org/medically-necessary-reasonable
Who are the Stakeholders When Contracting for Mental and Behavioral Health Services?
This discussion article identifies the key stakeholders involved in health plan contracting and their roles in shaping agreements. It categorizes stakeholders such as providers, health plans, patients, and regulators, outlining their interests and influence on contract terms. The article also discusses how the priorities of each group can sometimes conflict, impacting the negotiation process and the implementation of value-based care models. Strategies for balancing these interests to create fair and effective contracts are also presented.
https://www.mentorresearch.org/who-are-stakeholders-in-contracting
Risk Pools: How can they be Manipulated by Healthplans?
This discussion paper analyzes how health plans can manipulate risk pools in value-based payment models. It describes tactics such as selective patient inclusion, skewing risk scores, and using narrow definitions to shift financial risk onto providers. The paper outlines the impact of these practices on provider reimbursement and care quality, emphasizing the need for transparency and standardized criteria to prevent misuse. Recommendations for safeguarding against these manipulations are also discussed.
https://www.mentorresearch.org/risk-pools-how-can-they-be-manipulated-by-healthplans
High Case-Mix Severity Must be Considered in Value-Based Contracting.
This discussion paper addresses the importance of considering high case mix severity in value-based contracting. It explains how failing to account for complex patient populations can lead to unfair performance evaluations and inadequate reimbursement for providers. The paper highlights the need for risk adjustment methods that accurately reflect patient severity to ensure that value-based contracts are equitable and do not penalize providers who treat high-risk patients. Strategies for implementing effective risk adjustment measures are also discussed.
https://www.mentorresearch.org/high-case-mix-severity-must-be-considered-in-valuebased-contracting
Plain Language Collaboration Agreement and Use Case Example.
This discussion article explores the importance of using plain language in health plan contracts and provides a use case example to illustrate its application. It highlights how complex legal jargon can create misunderstandings, hinder compliance, and obscure critical terms for providers. The article outlines strategies for drafting clear agreements, emphasizing readability, transparency, and the use of standardized definitions. The use case example demonstrates how adopting plain language can facilitate better communication and improve trust in contractual relationships.
https://www.mentorresearch.org/plain-language-contract-agreement-and-use-case-example
Provider Practice and Value-Based Payment Contracting for Psychotherapy Services: Requirements and Challenges.
This article discusses the implementation of value-based payments in psychotherapy and its implications for clinical practice. It outlines how traditional fee-for-service models differ from value-based approaches that tie reimbursement to treatment outcomes and patient satisfaction. The article explores the benefits and challenges of transitioning to these models, including issues related to outcome measurement, data reporting, and aligning clinical practices with value-based goals. Strategies for integrating value-based principles into psychotherapy settings are also highlighted
https://www.mentorresearch.org/value-based-payments-psychotherapy
Why do Providers Avoid Conflicts with Healthplans?
This discussion paper explores why providers tend to avoid conflicts with health plans, even when facing unfavorable contract terms. It highlights contributing factors such as fear of losing patient referrals, concerns over being excluded from networks, and the time-consuming nature of disputes. The paper also discusses the negative impact this avoidance can have on both care quality and provider autonomy. Recommendations for creating a more balanced environment, including stronger legal protections and transparent dispute resolution mechanisms, are also presented.
https://www.mentorresearch.org/why-do-provider-avoid-conflicts-with-healthplans
Risks, Reasons, and What to Do When Healthplan Measurement and Value-Based Payment Contracts are a Contract of Adhesion.
This discussion article examines the risks associated with contracts of adhesion in health plan agreements, where one party has significantly more power in setting the terms. It outlines how these contracts can impose unfair conditions, limit provider options, and create ethical concerns. The article discusses strategies to recognize and address such imbalances, including negotiating for fairer terms, advocating for clearer definitions, and considering legal options when faced with coercive clauses. Recommendations for ensuring more equitable contracting practices are also included.
https://www.mentorresearch.org/risks-reasons-and-what-to-do-with-contracts-of-adhesion
The Problem When Contracts of Adhesion are Offered to Mental and Behavioral Health Providers
This discussion article addresses the problems that arise when contracts of adhesion are offered by health plans. It describes how these take-it-or-leave-it agreements can place providers at a disadvantage by limiting their ability to negotiate terms or opt for alternative arrangements. The article highlights the ethical and practical concerns associated with these contracts, including reduced provider autonomy and increased financial risk. Strategies for managing these challenges, such as advocating for clearer contract language and seeking independent legal review, are also discussed.
https://www.mentorresearch.org/problem-when-contracts-of-adhesion-are-offered
Transition from Fee-for-Service Step-wise to Alternative Payment Contracts and then Value-Based Payment Contracts: The Good and the Bad.
This discussion paper outlines a framework for transitioning fee-for-service psychotherapy to value-based payment contracts. It discusses key principles of value-based care, such as outcome measurement, quality improvement, and aligning financial incentives with patient outcomes. The paper highlights challenges related to implementing these changes, including workflow adjustments and reimbursement fairness, and offers strategies for successful adoption. Recommendations for providers and health plans to collaborate in restructuring service delivery models are also presented.
https://www.mentorresearch.org/transforming-feeforservice-psychotherapy-to-valuebased-payment-contract
Healthy Contracts: Ensuring Ethical and Collaborative Agreements in Mental Health Services.
This discussion article explores how to create healthy contracts that promote ethical and collaborative agreements in mental health services. It emphasizes the importance of fairness, transparency, and mutual respect in contracting to ensure that both providers and health plans can meet patient care goals effectively. The article outlines key elements of ethical contracts, such as clear terms, balanced responsibilities, and mechanisms for addressing disputes. Strategies for fostering trust and collaboration between contracting parties are also discussed.
https://www.mentorresearch.org/healthy-contracts-ensuring-ethical-and-collaborative-agreements-in-mental-health-services
Contracts Shall Include Complete Descriptions of Reimbursement Algorithms Such that Another Auditor Following the Instructions Would Achieve the Same Results.
This discussion article examines the importance of including complete descriptions of reimbursement algorithms in health plan contracts. It outlines how vague or incomplete algorithm descriptions can lead to confusion, billing disputes, and financial uncertainty for providers. The article recommends incorporating transparent and detailed language to clarify how reimbursement is calculated, ensuring that providers fully understand payment terms and reducing the risk of misinterpretation. Approaches for negotiating clearer contract language are also discussed.
https://www.mentorresearch.org/complete-descriptions-of-reimbursement-algorithms-in-contracts
Contracts and Policies Shall be Written in Plain, Understandable Language.
This discussion paper advocates for health plan contracts and policies to be written in plain language. It explains how complex legal jargon can create misunderstandings, hinder compliance, and lead to disputes between providers and health plans. The paper emphasizes the benefits of using clear, straightforward language, including improved communication, enhanced trust, and easier contract implementation. Recommendations for adopting plain language standards and examples of effective contract language are also provided.
https://www.mentorresearch.org/contracts-and-policies-shall-be-written-plain-language
Contracts and Policies Shall Include Transparent and Shared Values, Objectives, Controls, and Key Indicators Of Success.
This discussion paper addresses the importance of incorporating transparent and shared values, objectives, controls, and key performance indicators in health plan contracts. It explains how aligning these elements can promote accountability and trust between providers and health plans. The paper outlines strategies for defining common goals, measuring performance, and ensuring both parties are committed to shared standards. Potential benefits include improved collaboration, enhanced service quality, and more effective management of contractual relationships.
https://www.mentorresearch.org/including-transparent-and-shared-values-objectives-controls-and-key-indicators

“Take-It-Or-Leave-It” Unenforceable and Voidable Contracts

Problems When Contracts of Adhesion are Offered to Mental and Behavioral Health Providers.
This discussion article examines the challenges posed by contracts of adhesion in health plan agreements. It describes how these non-negotiable contracts can create power imbalances, limit providers’ ability to advocate for fair terms, and increase their exposure to financial risk. The article highlights ethical concerns and potential legal implications, while also suggesting strategies for negotiating better terms or avoiding these contracts altogether. Solutions such as enhanced legal protections and clearer contract standards are discussed to promote more equitable agreements.
https://www.mentorresearch.org/problem-when-contracts-of-adhesion-are-offered
What Can Happens if Voidable Provisions in Value-Based Contracts Go Unchallenged?
This discussion paper explores the implications of voidable provisions in health plan contracts. It explains how these clauses can be used to unilaterally alter or terminate key terms, creating uncertainty and potential legal risks for providers. The paper discusses strategies for identifying and addressing voidable provisions during contract review, advocating for clearer language and mutual consent when changes are made. Recommendations for ensuring more stable and transparent contracting practices are also included.
https://www.mentorresearch.org/contracts-with-voidable-provisions
Preventing the Problems Created by “Take It or Leave It” Contracts in Mental and Behavioral Health Services?
This discussion paper addresses strategies for preventing contracts of adhesion that negatively impact public health. It explains how these one-sided agreements can undermine provider autonomy, restrict patient access to care, and prioritize financial interests over health outcomes. The paper outlines policy recommendations, such as enforcing fair contract standards, promoting transparency, and establishing legal safeguards to protect against coercive practices. The broader implications for health equity and quality of care are also discussed.
https://www.mentorresearch.org/preventing-contract-of-adhesion-that-harm-public-health
Enforceable and Unenforceable Mental and Behavioral Health Contract Requirements.
This discussion paper outlines key requirements for making health plan contracts enforceable. It explains how clear terms, mutual consent, and adherence to legal standards are essential for creating binding agreements that protect both parties. The paper discusses common pitfalls, such as vague language or hidden clauses, that can render contracts unenforceable and increase the risk of disputes. Recommendations for ensuring contract compliance and promoting fair, transparent agreements are also provided.
https://www.mentorresearch.org/enforceable-contract-requirements
What Problems are Created When Healthplans Offer Providers “Take it or Leave it” Contracts of Adhesion?
This discussion article examines the impact of take-it-or-leave-it contracts in healthcare. It describes how these contracts, which offer no room for negotiation, can disadvantage providers by imposing unfavorable terms and limiting their ability to advocate for better conditions. The article highlights the ethical concerns and financial risks associated with these agreements and offers strategies for resisting or renegotiating such terms. Policy solutions to promote more balanced contracting practices are also discussed.
https://www.mentorresearch.org/take-or-leave-contract-in-healthcare

Risk of Contract Success and Failure

Importance of Clear and Accountable Contract Requirements for Value-Based Payment Contracts.
This discussion paper emphasizes the importance of having clearly written and accountable contracts in healthcare. It explains how well-defined terms and transparent accountability measures can reduce misunderstandings, prevent disputes, and promote trust between providers and health plans. The paper outlines best practices for drafting contracts that include precise language, mutual responsibilities, and enforceable provisions, thereby supporting more effective and ethical business relationships.
https://www.mentorresearch.org/importance-of-clearly-written-and-accountable-contracts
Unethical Tactics in Pay-for-Performance: : How Health Plans Manipulate Provider Contracts in Value-Based Care.
This discussion paper examines unethical tactics used by health plans in pay-for-performance contracts. It describes practices such as manipulating performance metrics, using misleading contract language, and setting unrealistic benchmarks to reduce provider reimbursement. The paper discusses the impact of these tactics on care quality, provider trust, and patient outcomes, while offering recommendations for identifying and addressing unethical behaviors. Strategies for ensuring fair performance evaluations and promoting ethical contracting are also included.
https://www.mentorresearch.org/unethical-health0plan-tactics-in-pay-for-performance
Why Teachers, Counselors and Legislators Should Support the Healthy Contracts Legislation.
This discussion article outlines the need for healthy contract legislation to protect teachers, counselors, and other public sector employees from unfair health plan agreements. It explains how such legislation can promote transparency, prevent coercive practices, and ensure that contract terms prioritize employee well-being and access to care. The article highlights key legislative components, including standardized contract language, ethical oversight, and enforceable protections, to support fair and sustainable agreements in public sector employment.
https://www.mentorresearch.org/why-teachers-counselors-and-legislators-healthy-contract-legislation
Rule of Reason Analysis Using Prima-Facia Evidence of Fraud and Violations of Antitrust and Federal Regulations (A Discussion Paper)
This discussion paper explores the use of rule-of-reason analysis in evaluating health plan contracts through prima facie evidence. It explains how this legal framework assesses whether contract terms promote or restrain fair competition and examines factors such as market impact, intent, and overall effect on providers and patients. The paper outlines steps for gathering and presenting prima facie evidence to support claims of unfair practices, while discussing potential outcomes of applying this analysis in disputes.
https://www.mentorresearch.org/rule-of-reason-analysis-using-primafacia-evidence
Successful and Failed Case Studies of Measurement-Based Care and Value-Based Payment Contracts: Recommended Requirements.
This discussion article compares successful and failed value-based contracts in healthcare. It analyzes the key factors that contribute to each outcome, such as clear performance metrics, aligned incentives, and effective care coordination. The article highlights common pitfalls in failed contracts, including poor communication, misaligned goals, and inadequate data sharing. Lessons learned from these case studies are presented to guide the development of value-based contracts that can achieve better clinical and financial results.
https://www.mentorresearch.org/successful-and-failed-valuebased-contracts
Why do Providers Avoid Conflicts with Healthplans?
This discussion paper explores why providers often avoid conflicts with health plans despite facing unfavorable contract terms. It outlines factors such as fear of retaliation, potential exclusion from networks, and the administrative burden of disputes. The paper discusses how these dynamics can undermine providers’ ability to advocate for better conditions and impact care quality. Recommendations for addressing these challenges include stronger legal protections and transparent dispute resolution processes.
https://www.mentorresearch.org/why-do-provider-avoid-conflicts-with-healthplans
What Can Happen if Unfair, Bad Faith, Ambiguous, Ill-Defined, Unethical, or Voidable Provisions in Fee-For-Service and Value-Based Contracts Go Unchallenged?
This discussion paper examines the risks associated with voidable provisions in health plan contracts. It explains how these clauses allow one party to unilaterally alter or terminate key terms, creating instability and potential legal risks for providers. The paper outlines strategies for identifying and addressing voidable provisions, advocating for clearer contract language and mutual consent when changes are made. Recommendations for promoting more transparent and reliable contracting practices are also provided.
https://www.mentorresearch.org/contracts-with-voidable-provisions
The Dangers of Using an Ombudsman for Fraud and Antitrust Violations: Undermining Accountability and the Legal Process.
The paper discusses the risks of relying on ombudsmen to address cases of fraud and antitrust violations. It argues that ombudsmen may lack the authority and independence necessary to enforce accountability, potentially delaying or undermining legal actions. The discussion highlights how this approach can create conflicts of interest, allowing fraudulent practices to persist while giving a false impression of oversight. The paper advocates for stronger, independent regulatory mechanisms to handle such violations effectively.
https://www.mentorresearch.org/the-danger-of-using-an-ombudsman-in-cases-of-fraud-and-violations-for-antitrust
Unreasonable Constraints on Healthcare Professionals - Doe v. U.S. Health Care Systems.
This discussion paper addresses the impact of unreasonable constraints imposed on healthcare professionals through restrictive contract terms. It explains how such constraints—such as excessive administrative requirements, non-compete clauses, and limitations on clinical decision-making—can reduce provider autonomy, increase burnout, and negatively affect patient care. The paper provides strategies for negotiating more balanced agreements and advocates for regulatory reforms to protect healthcare professionals from coercive contract practices.
https://www.mentorresearch.org/unreasonable-constraints-on-healthcare-professionals
Can Providers Legally Boycott a Healthplan? - Ethical Reasons to Legally Boycott a Healthplan.
This discussion paper outlines ethical reasons for healthcare providers to consider boycotting a health plan. It discusses situations where health plans engage in unethical practices, such as manipulating contract terms, misrepresenting coverage, or undermining patient care. The paper highlights how participating in such contracts can compromise professional integrity and harm patient outcomes. Strategies for organizing a boycott, including legal considerations and advocacy efforts, are also discussed as a means to promote fairer contracting practices.
https://www.mentorresearch.org/ethical-reasons-to-boycott-a-healthplan
Will Healthplans Support the Healthy Contracts Legislation.
This discussion article examines whether health plans are likely to support healthy contract legislation designed to promote fairer agreements with providers. It analyzes health plans’ potential motivations for opposing or endorsing such reforms, including concerns over profitability, administrative burden, and public image. The article outlines the benefits of adopting transparent and ethical contract standards and suggests strategies for engaging health plans in meaningful dialogue to gain their support.
https://www.mentorresearch.org/will-healthplans-support-the-healthy-contracts-legislation
Will Value-Based Payments Harm Public Health and Provider Practices? Case Example.
This discussion paper reviews the implementation of value-based contracts in Oregon’s healthcare market. It highlights key initiatives, such as the Oregon Value-Based Payment Compact, and examines how these contracts aim to improve care quality and control costs. The paper discusses the challenges providers face, including adapting to new performance metrics and managing financial risk. Strategies for enhancing the effectiveness of value-based contracts in the state, such as improved data sharing and stronger care coordination, are also presented.
https://www.mentorresearch.org/value-based-contracts-in-oregon
Core Psychotherapy Values and the Erosion by Healthplan Practices.
This discussion paper explores how certain health plan practices can erode core psychotherapy values, such as patient autonomy, confidentiality, and the therapeutic alliance. It examines tactics like limiting session duration, restricting treatment options, and prioritizing cost over clinical need, which can undermine ethical care. The paper advocates for policies that protect the integrity of psychotherapy and offers strategies for resisting practices that conflict with core professional values.
https://www.mentorresearch.org/core-psychotherapy-values-and-the-erosion-by-healthplan-practices
Challenges in Implementing Value-Based Payment Contracts Using W-2 Mental and Behavioral Health Professionals.
This discussion article examines the challenges of implementing value-based payment contracts using W-2 mental health professionals. It discusses how employment structures, such as W-2 versus independent contractor arrangements, impact the ability to align performance incentives and manage clinical outcomes. The article highlights issues like reduced flexibility, administrative burdens, and potential conflicts between financial goals and clinical practice. Recommendations for adapting value-based models to suit W-2 employee structures are also provided.
https://www.mentorresearch.org/challenges-in-implementing-value-based-payment-contracts-using-w-2-mental-health-professionals

Good Faith and Fair Dealing

Signs of Bad Faith in Value-Based Payment Contracts for Mental and Behavioral Health Services Offered by Healthplans.
This discussion paper outlines signs of a bad faith value-based payment contract. It describes indicators such as vague performance metrics, unilateral changes to terms, and excessive administrative requirements that disadvantage providers. The paper also highlights how these contracts can undermine trust and compromise care quality. Strategies for identifying and avoiding bad faith contracts, as well as recommendations for promoting more transparent and equitable agreements, are also discussed.
https://www.mentorresearch.org/signs-of-a-bad-faith-valuebased-payment-contract
Good Faith and Fair Dealing in Healthcare Contracting for Fee-For-Service, Alternative and Value-Based Payment Models
This discussion paper examines the principles of good faith and fair dealing in health plan contracts. It explains how these concepts are meant to ensure honest communication, transparency, and mutual respect between contracting parties. The paper discusses common contract practices that violate these principles, such as hidden terms and deceptive language, and offers strategies for promoting ethical contracting through clearer definitions and enforceable standards. The broader impact on provider relationships and patient care is also considered
https://www.mentorresearch.org/good-faith-and-fair-dealing
Plain Language Contract and Use Case Example.
This discussion article emphasizes the importance of using plain language in health plan contracts and provides a use case example to illustrate its application. It explains how complex legal jargon can lead to misunderstandings, compliance issues, and power imbalances between providers and health plans. The article outlines strategies for creating clear, accessible agreements, highlighting benefits such as improved communication and trust. The use case demonstrates how plain language can simplify contract terms and promote more ethical contracting practices.
https://www.mentorresearch.org/plain-language-contract-agreement-and-use-case-example
How Can Mental and Behavioral Health Provider Practices Recognize They are Being “Taken for a Ride”?
This discussion paper examines how mental and behavioral health provider practices can be exploited through unfair health plan contracting practices. It describes tactics such as deceptive reimbursement structures, excessive administrative requirements, and restrictive network agreements that can diminish provider revenue and autonomy. The paper outlines the impact of these practices on service quality and sustainability, offering strategies for identifying and resisting exploitative contracts to protect provider interests.
https://www.mentorresearch.org/in-what-ways-are-mental-and-behavioral-health-provider-practices-being-taken-for-a-ride
The Problems When Contracts of Adhesion are Offered to Mental and Behavioral Health Providers.
This discussion article addresses the problems associated with contracts of adhesion in healthcare agreements. It explains how these non-negotiable contracts can create power imbalances, limit providers’ ability to advocate for fair terms, and increase their financial and legal risks. The article highlights the ethical and practical issues that arise from these agreements and offers strategies for negotiating more balanced terms or avoiding such contracts altogether. Recommendations for fostering fairer contracting practices are also discussed.
https://www.mentorresearch.org/the-problem-when-contracts-of-adhesion-are-offered
The Quadruple Aim: What Should Healthplans Do? & What Some Healthplans Say They're Doing.
This discussion paper explores the concept of the Quadruple Aim in healthcare, which extends the traditional Triple Aim by adding the goal of improving the work life of healthcare providers. It discusses how achieving the Quadruple Aim—enhancing patient experience, improving population health, reducing costs, and supporting provider well-being—requires addressing systemic issues such as burnout, administrative burden, and inefficient care models. The paper outlines strategies for aligning organizational practices with these objectives to create a more sustainable and effective healthcare system.
https://www.mentorresearch.org/the-quadruple-aim

Gaming, Fraud and Antitrust

Contract “Gaming”: Reasons Why Value-Based Contracts Can Fail.
This discussion paper analyzes various forms of contract gaming that can undermine the success of value-based contracts. It describes tactics such as manipulating patient risk scores, selective reporting of outcomes, and redefining performance metrics to skew results. The paper explains how these practices can distort the intended goals of value-based care, leading to mistrust and reduced effectiveness. Strategies to identify and prevent contract gaming, including stronger oversight and clearer definitions, are also discussed.
https://www.mentorresearch.org/contract-gaming-reasons-why-value-based-contracts-will-fail
Description of Healthcare Fraud in Measurement and Value-Based Care Contracting.
This discussion paper examines how healthcare fraud can manifest in value-based payment contracts. It outlines common fraudulent practices such as inflating performance metrics, misrepresenting patient data, and manipulating risk scores to maximize financial gains. The paper discusses the challenges of detecting and preventing fraud in these complex payment models and emphasizes the need for transparent data reporting and robust compliance measures. Strategies for minimizing fraud risk and promoting accountability in value-based contracts are also presented.
https://www.mentorresearch.org/healthcare-fraud-measurement-an-valuebased-payment-contracts
Bait and Switch Tactics - A Hypothetical Contract Recruitment Scenario?
This discussion paper explores bait-and-switch tactics used in healthcare contracting. It explains how health plans may initially offer favorable contract terms or reimbursement rates, only to change them unilaterally after providers have committed to the agreement. The paper highlights the impact of these tactics on provider revenue, care delivery, and trust in contracting relationships. Strategies for identifying and resisting bait-and-switch practices, along with recommendations for promoting fair and transparent contracts, are also discussed.
https://www.mentorresearch.org/bait-and-switch-tactics
Risk Pools: How can they be Manipulated by Healthplans?
This discussion paper analyzes how health plans can manipulate risk pools in value-based payment models. It outlines tactics such as selectively including or excluding certain patients, skewing risk scores, and using narrow definitions to shift financial risk onto providers. The paper discusses the impact of these manipulations on provider reimbursement, care quality, and overall contract fairness. Strategies for increasing transparency and implementing standardized criteria to prevent misuse are also provided.
https://www.mentorresearch.org/risk-pools-how-can-they-be-manipulated-by-healthplans
Description of Healthcare Fraud by using Provider Practices as a Proxy.
This discussion paper examines how healthcare fraud can occur within measurement and value-based contracting. It details fraudulent activities such as falsifying data, manipulating patient outcomes, and misrepresenting performance to achieve financial incentives. The paper explains how these actions undermine the integrity of value-based models and erode trust between providers and health plans. Strategies for identifying, preventing, and addressing fraud, including robust auditing and clearer performance metrics, are also discussed.
https://www.mentorresearch.org/healthcare-fraud-in-measurement-and-value-based-contracting
Preventing Healthplan Fraud on Mental Health Professionals.
This discussion paper addresses strategies for preventing health plan fraud, particularly in the context of value-based contracts. It describes common fraudulent practices, such as manipulating quality measures, inflating costs, and misrepresenting patient data, which can undermine care quality and financial stability. The paper emphasizes the importance of transparency, standardized reporting, and independent audits to detect and deter fraud. Recommendations for creating more robust anti-fraud policies and promoting ethical contracting practices are also provided.
https://www.mentorresearch.org/preventing-healthplan-fraud
Is Moda Health Violating Antitrust Law?
This discussion paper examines whether Moda Health’s contracting practices may violate antitrust laws. It analyzes how certain behaviors, such as limiting provider networks, restricting competition, and using exclusionary tactics, could create unfair market advantages. The paper outlines the potential antitrust implications of Moda Health’s actions and discusses how these practices may impact market pricing, provider autonomy, and patient access to care. Recommendations for further investigation and strategies to address potential antitrust violations are also included.
https://www.mentorresearch.org/is-moda-health-violating-antitrust-law
Value-Based Payment Fraud: When Heathplan Misrepresentation Turns into Conspiracy.
This discussion paper explores strategies to prevent health plan fraud, particularly in value-based payment models. It outlines common forms of fraud, such as inflating performance metrics, misclassifying patients, and falsifying outcome data, which can distort reimbursement and undermine trust. The paper emphasizes the need for transparent data reporting, independent audits, and standardized performance measures to detect and deter fraudulent behavior. Recommendations for strengthening compliance and promoting ethical practices in health plan contracting are also provided.
https://www.mentorresearch.org/preventing-healthplan-fraud
What can Happen if Unfair, Bad Faith, Ambiguous, Ill-Defined, Unethical, or Voidable Provisions in Fee-For-Service and Value-Based Contracts go Unchallenged?
This discussion paper examines the risks posed by voidable provisions in health plan contracts. It explains how these clauses allow one party to unilaterally modify or cancel key terms, creating legal and financial uncertainty for providers. The paper discusses strategies for identifying voidable provisions and negotiating clearer, mutually enforceable terms. Recommendations for promoting more transparent and stable contracting practices are also presented.
https://www.mentorresearch.org/contracts-with-voidable-provisions
Collaboration Agreements For Value-Based Payment Contracting.
This article discusses the role of collaboration agreements in value-based payment contracting. It explains how these agreements define shared responsibilities, financial arrangements, and performance expectations between providers and health plans. The article emphasizes the importance of trust, clear communication, and aligning care goals to support successful partnerships. Key considerations for structuring collaboration agreements, such as risk-sharing and compliance with regulatory requirements, are also highlighted.
https://www.mentorresearch.org/collaboration-agreements-for-valuebased-payment-contracting
Intersection of Mental Health, Value-Based Payment Contracts, and the Law: A Case Study of Moda Health.
This discussion paper presents a case study on integrating mental health services into value-based contracts. It examines the unique challenges of applying value-based models to mental health care, such as measuring outcomes, managing risk, and coordinating care between behavioral and physical health. The paper provides insights into successful strategies for overcoming these challenges, including establishing clear performance metrics and aligning incentives to support both clinical and financial goals.
https://www.mentorresearch.org/intersection-of-mental-health-and-value-based-contracts-a-case-study
Healthy Versus Toxic Contracts
This discussion paper contrasts healthy and toxic contracts in healthcare and examines how contract conversations and audits can either strengthen or undermine provider-health plan relationships. It outlines the characteristics of healthy contracts, such as clear terms, mutual accountability, and ethical safeguards, compared to toxic agreements that impose unfair conditions and lack transparency. The paper discusses the role of audits in ensuring contract compliance and offers strategies for fostering constructive dialogue to promote ethical contracting.
https://www.mentorresearch.org/healthy-toxic-contracts-conversations-and-audits
Informed Consent Motivates Patients to Game Outcome Measures.
This discussion paper examines how informed consent requirements can unintentionally encourage gaming of outcome measures in value-based contracts. It explains how the transparency needed for patient consent might lead some providers to manipulate data or selectively report outcomes to align with performance benchmarks. The paper discusses the ethical dilemmas this creates and offers strategies to mitigate gaming, including clearer metrics, better oversight, and adjustments to consent processes.
https://www.mentorresearch.org/informed-consent-motivates-gaming-outcome-measures

Ethics Point Portal: Definition and Benefits for Value-Based Contracts in Mental and Behavioral Health Services.
This discussion paper defines an ethics point portal and explores how these portals provide a secure and anonymous way for providers to report unethical practices, compliance issues, or contract violations. The paper highlights the role of ethics point portals in promoting transparency, accountability, and trust within organizations. Recommendations for implementing effective portals, including ensuring accessibility and independence from management, are also discussed.
https://www.mentorresearch.org/ethics-point-portal-definition-and-benefits
Ethics-Point Portals Overseen by Independent Certified Internal Auditor's: A Resource to Serve Stakeholders and the Healthplans
This discussion paper explains how independent oversight ensures that reports of unethical practices or contract violations are handled objectively and free from internal influence. The paper outlines the benefits of this structure, including enhanced trust, better compliance, and reduced risk of retaliation against reporters. Recommendations for establishing and maintaining independent audit oversight are also provided.
https://www.mentorresearch.org/ethics-point-portals-overseen-by-independent-certified-internal-auditor
The Results of Audits and Mitigation Options Should be Posted on a Public Electronic Platform Webpage.
This discussion paper explains how publicly accessible information can enhance transparency, reduce misunderstandings, and allow for greater accountability in contract negotiations. The paper discusses how this practice supports ethical contracting by enabling providers and stakeholders to review and compare contract terms easily. Strategies for implementing public posting while protecting sensitive information are also outlined.
https://www.mentorresearch.org/posted-on-a-public-electronic-platform-webpage
Contracts And Policies Shall Undergo 90 To 120-Day Review Period To Gather Stakeholder Feedback.
This discussion paper advocates for requiring health plan contracts and policies to undergo a 90- to 120-day review period to gather stakeholder feedback. It explains how this extended review process allows providers, patients, and other stakeholders to assess terms, identify potential issues, and suggest improvements before agreements are finalized. The paper highlights how this approach promotes transparency, prevents misunderstandings, and leads to more balanced and effective contracts. Recommendations for structuring the review period to maximize stakeholder input are also provided.
https://www.mentorresearch.org/contracts-and-policies-shall-undergo-90-to-120day-review-period-to-gather-stakeholder-feedback

Independent Certified Internal Auditor

Independent Certified Internal Auditor – Example Job Description
This discussion paper defines the role of an independent certified internal auditor (CIA) in health plan contracting and governance. It explains how having an independent auditor ensures that compliance reviews and investigations into unethical practices are conducted impartially. The paper highlights the benefits of using certified internal auditors, including increased trust, transparency, and accountability in health plan operations. Recommendations for integrating independent CIAs into organizational oversight structures are also discussed.
https://www.mentorresearch.org/independent-certified-internal-auditor
A 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.
This discussion paper examines the value and importance of independent internal auditors in health plan contracting. It explains how independent auditors provide objective oversight, detect compliance issues, and ensure that contract terms are upheld fairly. The paper highlights the role of independent internal auditors in promoting ethical practices, reducing fraud, and enhancing trust between providers and health plans. Recommendations for implementing effective audit processes and ensuring auditor independence are also provided.
https://www.mentorresearch.org/value-and-importance-of-independent-internal-auditors
How Can an Independent Certified Internal Auditor Support Mental and Behavioral Health Contracting.
This discussion paper explores how an independent certified internal auditor (CIA) can support health plan contracting and compliance. It explains how CIAs provide objective oversight by identifying unethical practices, ensuring adherence to contractual terms, and enhancing transparency. The paper discusses the benefits of using independent auditors, such as improved accountability, reduced fraud risk, and increased trust between health plans and providers. Strategies for integrating independent auditors into governance frameworks are also outlined.
https://mentorresearch.org/how-can-an-independent-certified-internal-auditor-support
How and Why Should the Independence of Certified Internal Auditors be Ensured?
This discussion paper addresses the importance of maintaining the independence of internal auditors in health plan contracting. It explains how independent auditors can objectively evaluate compliance, detect unethical practices, and provide unbiased recommendations without external influence. The paper highlights common threats to auditor independence, such as conflicts of interest and management pressure, and offers strategies for preserving impartiality, including clear reporting structures and adherence to professional standards.
https://www.mentorresearch.org/maintaining-independence-of-internal-auditors
Independent Certified Internal Auditor: The Bridge Between Stakeholder and the Healthplan.
This discussion paper advocates for independent auditors to serve as a point of contact for stakeholders in health plan contracts. It explains how having auditors in this role enables stakeholders to report concerns about unethical practices or contract violations safely and confidentially. The paper outlines benefits such as improved transparency, enhanced trust, and more effective resolution of compliance issues. Strategies for maintaining auditor independence and ensuring that stakeholder input is addressed impartially are also discussed.
https://www.mentorresearch.org/auditor-shall-be-a-point-of-contact-for-stakeholders
The 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 explores the role of independent auditors in reviewing reports registered through health plan ethics portals. It explains how auditors can verify the accuracy of these reports, identify patterns of unethical behavior, and ensure that concerns are addressed transparently. The paper highlights how independent audits promote accountability and reduce the risk of retaliation against those who report issues. Recommendations for structuring audit processes and maintaining auditor impartiality are also provided.
https://www.mentorresearch.org/auditor-shall-audit-reports-registered
The Independence of Healthplan Auditors Must Comport with Standards Set the U.S. Office of Inspector General U.S. Office of Inspector General (OIG).
This discussion paper outlines the value of using Office of Inspector General (OIG) standards in health plan contracting and compliance. It explains how OIG standards provide a framework for preventing fraud, waste, and abuse through clear guidelines on ethics, accountability, and internal controls. The paper discusses how adopting these standards can promote transparency, enhance oversight, and build trust between providers and health plans. Recommendations for integrating OIG standards into organizational policies and practices are also included.
https://www.mentorresearch.org/why-use-oig-standards
What Can Certified Internal Auditors Do That Will Prevent Healthplans From “Gaming” Providers, Purchasers, and The Public?
This discussion paper examines how value-based contracts can be manipulated through gaming tactics. It describes strategies such as selectively choosing patients, inflating risk scores, and misrepresenting outcomes to maximize financial incentives while undermining the contract’s intent. The paper discusses the impact of these practices on care quality, provider trust, and the effectiveness of value-based models. Recommendations for preventing gaming, including implementing clearer performance metrics and stronger oversight, are also provided.
https://www.mentorresearch.org/gaming-a-valuebased-contract
Why is Hiring an Independent Certified Internal Auditor a Good Idea?
This discussion paper highlights the benefits of hiring an independent certified internal auditor (CIA) in health plan contracting. It explains how CIAs provide objective oversight, identify compliance issues, and ensure that contractual obligations are met fairly. The paper discusses how using independent auditors can promote transparency, reduce fraud risk, and build trust between contracting parties. Recommendations for selecting and integrating independent auditors into organizational governance are also included.
https://www.mentorresearch.org/why-hiring-an-independent-certified-internal-auditor-is-a-good-idea

Value, Objectives, Controls, Tests of Design and Effectiveness, Key Indicators of Success

Controls in Fee-For-Service, Alternative and Value-Based Payment Contracting.
This discussion paper defines the concept of a "control" in the context of health plan contracting and compliance. It explains how controls are mechanisms put in place to ensure that operations align with established policies, prevent unethical behavior, and detect potential issues. The paper outlines different types of controls, such as preventative, detective, and corrective controls, and discusses their role in promoting accountability and reducing risk. Strategies for implementing effective controls within contracting frameworks are also provided.
https://www.mentorresearch.org/what-is-a-control
What is a Control Library?
This discussion paper explains the purpose and benefits of maintaining a control library in health plan contracting. It describes how a control library serves as a centralized repository of all policies, procedures, and compliance measures used to monitor and manage contract performance. The paper highlights how a well-organized control library supports transparency, standardizes practices, and ensures that all stakeholders are aligned on compliance expectations. Recommendations for building and maintaining an effective control library are also discussed.
https://www.mentorresearch.org/control-library
Controls, Tests of Design (TOD) and Tests of Effectiveness (TOE) in Measurement and Value-Based Contracting For Mental and Behavioral Health Services.
The paper outlines the distinction between tests of design and tests of effectiveness in healthcare programs and interventions. It contrasts how design tests assess whether an intervention is implemented as intended, while effectiveness tests evaluate the outcomes and impact on target populations. The discussion emphasizes the importance of using both types of assessments to ensure interventions are not only well-constructed but also achieve meaningful results in real-world settings.
https://www.mentorresearch.org/tests-of-design-and-tests-of-effectiveness
Core Psychotherapy Values and the Erosion by Healthplan Practices.
This discussion paper explores the concepts of tests of design and tests of effectiveness in health plan contracting. It explains how tests of design evaluate whether a control is appropriately structured to meet its objectives, while tests of effectiveness assess whether the control is functioning as intended in practice. The paper highlights the importance of using both types of tests to ensure robust compliance and reduce risks. Recommendations for implementing these tests and addressing deficiencies are also provided.
https://www.mentorresearch.org/core-psychotherapy-values-and-the-erosion-by-healthplan-practices
Importance of Transparent Shared Values, Objectives, Controls, Key Indicators of Success, Tests of Design, and Tests of Effectiveness in Value-Based Payment Contracts for Mental and Behavioral Health Services.
This discussion paper examines the importance of shared values, objectives, and indicators of success in health plan contracting. It explains how aligning these elements between providers and health plans promotes mutual trust, enhances collaboration, and supports long-term success. The paper outlines strategies for defining common goals and establishing clear performance metrics to ensure that all parties are working toward the same outcomes. Recommendations for maintaining alignment and addressing conflicts are also included.
https://www.mentorresearch.org/importance-of-shared-values-objectives-indicators-of-success

Ethics Point Portal

Ethics Point Portal: Definition and Benefits for Value-Based Contracts in Mental and Behavioral Health Services.
This discussion paper defines ethics point portals and outlines their benefits in health plan contracting. It explains how these portals provide a secure and confidential way for stakeholders to report unethical practices, compliance concerns, or contract violations. The paper highlights how ethics point portals promote transparency, accountability, and ethical conduct within organizations. Recommendations for implementing effective portals, including ensuring independence and accessibility, are also discussed.
https://www.mentorresearch.org/ethics-point-portal-definition-and-benefits
Ethics-Point Portals Overseen by Independent Certified Internal Auditors (CIA): A Resource to Serve Stakeholders and the Public.
This discussion paper emphasizes the importance of having ethics point portals overseen by an independent certified internal auditor (CIA). It explains how independent oversight ensures that reports of unethical practices or contract violations are handled objectively and free from internal influence. The paper highlights the benefits of this structure, such as increased trust, better compliance, and reduced risk of retaliation against reporters. Recommendations for maintaining auditor independence and promoting transparent investigations are also included.
https://www.mentorresearch.org/ethics-point-portals-overseen-by-independent-certified-internal-auditor
The Results of Audits and Mitigation Options Should be Posted on a Public Electronic Platform Webpage.
This discussion paper advocates for posting health plan contracts and policies on a public electronic platform or webpage. It explains how public access to these documents can enhance transparency, reduce misunderstandings, and allow for greater accountability in contract negotiations. The paper highlights the benefits of this approach, such as enabling stakeholders to review and compare contract terms more easily. Strategies for implementing public posting while protecting sensitive information are also provided.
https://www.mentorresearch.org/posted-on-a-public-electronic-platform-webpage
The 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 examines the role of independent auditors in reviewing reports registered through health plan ethics portals. It explains how auditors can verify the accuracy of these reports, identify patterns of unethical behavior, and ensure concerns are addressed transparently. The paper highlights how independent audits promote accountability and reduce the risk of retaliation against those who report issues. Recommendations for structuring audit processes and maintaining auditor impartiality are also discussed.
https://www.mentorresearch.org/auditor-shall-audit-reports-registered
Empowering Providers to Report Suspicious, Unethical, and Illegal Behaviors.
The paper discusses strategies for empowering healthcare providers to report unethical, illegal, and suspicious behaviors. It emphasizes the importance of establishing clear reporting channels, protections against retaliation, and education on recognizing misconduct. The discussion highlights how fostering a culture of accountability and transparency can encourage providers to act without fear, ultimately improving the integrity and quality of healthcare services.
https://www.mentorresearch.org/empowering-providers-to-report-suspicious-unethical-and-illegal-behaviors
Contracts And Policies Shall Be Written In Plain, Understandable Language.
This discussion paper advocates for health plan contracts and policies to be written in plain language. It explains how complex legal jargon can create confusion, hinder compliance, and lead to disputes between providers and health plans. The paper highlights the benefits of using clear and straightforward language, including improved communication, enhanced trust, and more efficient contract implementation. Strategies for adopting plain language standards and examples of effective contract language are also provided.
https://www.mentorresearch.org/contracts-and-policies-shall-be-written-plain-language

Audits

Medically Necessary and Reasonable Psychotherapy Services.
This discussion paper explores the definitions and implications of the terms “medically necessary” and “reasonable” in health plan contracts. It explains how varying interpretations of these terms can impact service authorization, reimbursement, and patient access to care. The paper highlights how unclear definitions can lead to disputes between providers and health plans and recommends adopting standardized language to ensure consistent decision-making and promote fair coverage practices.
https://www.mentorresearch.org/medically-necessary-reasonable
Five Types of Psychotherapy Audits.
This discussion paper explores the purpose and impact of psychotherapy practice audits in health plan contracting. It describes how audits assess clinical practices, adherence to contract terms, and billing accuracy. The paper highlights both the potential benefits, such as enhancing care quality and ensuring compliance, and the risks, including the possibility of being used to reduce provider reimbursements or impose punitive measures. Recommendations for navigating audits and maintaining practice integrity are also provided.
https://www.mentorresearch.org/psychotherapy-practice-audits
Healthplan and Medicare Advantage Risk Scores and “Clawbacks”
This discussion paper examines Medicare Advantage risk adjustments and clawback practices. It explains how health plans use risk adjustments to modify payments based on the health status of enrollees and how clawbacks are implemented to recover funds when risk scores are later adjusted. The paper highlights concerns about the potential for manipulation, which can lead to financial instability for providers. Strategies for managing risk adjustments and ensuring fair reimbursement practices are also discussed.
https://www.mentorresearch.org/medicare-advantage-risk-adjustments-and-clawbacks

Employee Retirement Income Security Act (ERISA)

ERISA and The History Of Conflict With Psychotherapy Practice
This discussion paper examines the history of conflict between the Employee Retirement Income Security Act (ERISA) and psychotherapy practice. It explains how ERISA’s preemption of state regulations has led to challenges in enforcing mental health parity and fair reimbursement practices. The paper outlines the impact of ERISA on psychotherapy services, including limitations on provider protections and patients’ ability to appeal denied claims. Strategies for addressing these conflicts, such as legislative reforms and enhanced provider advocacy, are also discussed.
https://www.mentorresearch.org/erisa-and-the-history-of-conflict-with-psychotherapy-practice
Alignment of ERISA with Healthy Contracts Legislation: Supported by Federal Regulations
This discussion paper explores how aligning ERISA with healthy contracts legislation is supported by federal regulations. It explains how recent regulatory changes aim to enhance transparency, accountability, and fairness in health plan contracting. The paper discusses how aligning ERISA provisions with these goals can address historical conflicts, improve provider protections, and support more equitable contract practices. Strategies for leveraging federal regulations to promote healthy contracts in psychotherapy and other healthcare services are also outlined.
https://www.mentorresearch.org/aligning-erisa-with-healthy-contracts-legislation-is-supported-by-federal-regulations
Understanding and Overcoming ERISA Preemption Doctrine using Healthy Contracts.
This discussion paper explores how providers can address the challenges of ERISA by implementing healthy contract principles. It explains how ERISA’s preemption of state laws creates barriers to enforcing fair reimbursement and provider protections. The paper outlines strategies such as using clear contract language, advocating for federal compliance, and leveraging recent regulatory changes to improve fairness in ERISA-governed health plans. Recommendations for aligning contracts with healthy practices to protect provider interests and ensure ethical contracting are also discussed.
https://www.mentorresearch.org/understanding-and-overcoming-erisa-using-healthy-contracts

Legislative Opportunities

3 Ways to Improve House Bill 4069.
https://www.mentorresearch.org/3-ways-to-improve-house-bill-4069
Fiduciary Responsibility in Healthplan Contracting: A Critical Examination.
https://www.mentorresearch.org/fiduciary-responsibility-in-healthplan-contracting-a-critical-examination
Will Healthplans Support the Healthy Contracts Legislation?
https://www.mentorresearch.org/contract-gaming-reasons-why-value-based-contracts-will-fail

Healthplan Waste

Charting Requirements are Not Patient-Centered
This discussion paper critiques how standard charting requirements in health plan contracts can be misaligned with patient-centered care. It explains how these requirements often prioritize administrative needs, such as billing and compliance, over clinical relevance and patient engagement. The paper highlights how excessive documentation can burden providers and detract from the therapeutic process. Recommendations for creating charting practices that better support patient-centered care, while still meeting regulatory and contractual obligations, are also discussed.
https://www.mentorresearch.org/charting-requirements-are-not-patient-centered
What is the Value of Charting in Psychotherapy Practice?
This discussion paper examines the value of psychotherapy charting in the context of health plan requirements. It explains how detailed and meaningful documentation can support treatment planning, demonstrate clinical effectiveness, and justify the medical necessity of services. The paper contrasts this with the risks of over-documentation, which can increase administrative burden and reduce time for patient care. Strategies for balancing thorough charting with efficiency and maintaining alignment with value-based care principles are also provided.
https://www.mentorresearch.org/value-psychotherapy-charting
Psychotherapy Treatment Plans & Progress Notes can Have Chilling Effects on Patients, Outcomes, Satisfaction and Dropout.
This discussion paper explores the "chilling effect" that excessive charting requirements can have on patient outcomes in psychotherapy. It explains how overemphasis on documentation for compliance and billing purposes can undermine the therapeutic relationship, reduce patient trust, and shift the focus away from patient-centered care. The paper discusses how these practices may discourage open communication, impacting the quality of care and treatment effectiveness. Strategies for minimizing the negative impact of charting requirements while maintaining necessary compliance are also provided.
https://www.imhpa.org/charting-chilling-effect-on-patients-outcomes
Measurement-Based and Outcome Informed Care: Enhancing Mental Health Treatment Outcomes.
This discussion paper explores the "chilling effect" that excessive charting requirements can have on patient outcomes in psychotherapy. It explains how overemphasis on documentation for compliance and billing purposes can undermine the therapeutic relationship, reduce patient trust, and shift the focus away from patient-centered care. The paper discusses how these practices may discourage open communication, impacting the quality of care and treatment effectiveness. Strategies for minimizing the negative impact of charting requirements while maintaining necessary compliance are also provided.
https://www.mentorresearch.org/comparing-measurement-basedcare-and-feedback-informed-treatment
Medically Necessary and Reasonable Psychotherapy Services.
This discussion paper explores the definitions and implications of the terms “medically necessary” and “reasonable” in health plan contracts. It explains how varying interpretations of these terms can influence service authorization, reimbursement, and patient access to care. The paper highlights how unclear definitions can lead to disputes between providers and health plans, impacting clinical decision-making and coverage determinations. Recommendations for adopting standardized language to ensure consistency and fairness in medical necessity determinations are also provided.
https://www.mentorresearch.org/medically-necessary-reasonable

Healthplan Discussion Papers

DISCLAIMER and PURPOSE: These discussion documents are intended for training, education, and 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

Mentor Research Institute