PHYSICIAN INCENTIVE PLAN. If CONTRACTOR wants to institute a Physician Incentive Plan, CONTRACTOR shall submit the proposed plan to the COUNTY which will in turn submit the Plan to the State for approval, in accordance with the provisions of 42 C.F.R. § 438.6(c).
PHYSICIAN INCENTIVE PLAN. 8.5.1 The Contractor may establish physician incentive plans pursuant to federal and State regulations, including 42 CFR 422.208 and 422.210, and 42 CFR 438.6.
8.5.2 The Contractor shall disclose any and all such arrangements to DCH, and upon request, to Members. Such disclosure shall include: · Whether services not furnished by the physician or group are covered by the incentive plan; · The type of Incentive Arrangement; · The percent of Withhold or bonus; and, · The panel size and if patients are pooled, the method used.
8.5.3 Upon request, the Contractor shall report adequate information specified by the regulations to DCH in order that DCH will adequately monitor the CMO plan.
8.5.4 If the Contractor’s physician incentive plan includes services not furnished by the physician/group, the Contractor shall: (1) ensure adequate stop loss protection to individual physicians, and must provide to DCH proof of such stop loss coverage, including the amount and type of stop loss; and (2) conduct annual Member surveys, with results disclosed to DCH, and to Members, upon request.
8.5.5 Such physician incentive plans may not provide for payment, directly or indirectly, to either a physician or physician group as an inducement to reduce or limit medically necessary services furnished to an individual.
PHYSICIAN INCENTIVE PLAN. If Contractor wants to institute a Physician Incentive Plan, Contractor shall submit the proposed plan to County which will in turn submit the Plan to the State for approval, in accordance with the provisions of Title 42, CFR section 438.6(h).
PHYSICIAN INCENTIVE PLAN. The Contractor may operate a physician incentive plan (PIP) only if no specific payment can be made directly or indirectly under a PIP to a physician or physician group as an inducement to reduce or limit medically necessary services furnished to an Enrollee. Contracts must be in compliance with the requirements set forth in 42 CFR §§ 422.208 and 422.210. The Contractor shall provide to the Division of Medicaid the following disclosure:
a. Whether services not furnished by physician/group is covered by incentive plan. If the PIP does not cover services furnished by physician/group, no further disclosure is required.
b. The type of incentive arrangement, e.g. withhold, bonus, capitation.
c. Percentage of withhold or bonus, if applicable.
d. Panel size, and if patients are pooled, the approved method used.
e. If the physician/group is at substantial financial risk, the Contractor must report proof the physician/group has adequate stop-loss coverage, including amount and type of stop-loss.
PHYSICIAN INCENTIVE PLAN. 10.7.1 The Contractor will design and implement a plan that evaluates the quality of care delivered by PCPs and provides financial incentives to promote PCPs’ commitment to Preventive Services (the “Physician Incentive Plan”). The Contractor will submit such plan to ASES for approval at on or before December 1, 2011, and ASES shall approve it no later than thirty (30) Calendar Days after its submission. The Provider Incentive Plan will include, at a minimum, the following components:
10.7.1.1 The Contractor shall allocate three cents ($0.03) PMPM of the Per Member Per Month Administrative Fee received from ASES to the Provider Incentive Plan (the “Provider Incentive Pool”).
10.7.1.2 Each PCP who reaches the minimum target, which shall be mutually established between ASES and the Contractor, for each of the criteria set forth below (the “Qualification Criteria”) shall receive a pro-rata portion of the Provider Incentive Pool.
10.7.1.3 The Contractor will review the Medical Records at the PMG or PCP level to ascertain and evidence the Preventive Services provided by the PCPs to Enrollees. ASES requires through this review that the PCPs comply with the documentation requirements established by the Health Department and EPSDT guidelines.
10.7.2 The Qualification Criteria shall be based, to the extent applicable, on certain HEDIS measures to be mutually agreed by the Parties and may include, without limitation, the following additional criteria:
10.7.2.1 That the PCP performs preventive screening to its population according to evidence based on clinical practice guidelines.
10.7.2.2 That the PCP provides early detection of population with neuro-developmental disorders and autism.
10.7.2.3 That the PCP adopts an EHR system that meets the specifications contained in Attachment 15 to this Contract.
10.7.2.4 That the PCP complies with the EPSDT screening and parent education requirements.
10.7.2.5 That the PCP complies with the requirements of a mental and physical health integration program to be mutually agreed between the Parties.
10.7.3 The Contractor will provide a quarterly report on the Physician Incentive Plan to ASES, which report shall contain, with respect to each Provider:
10.7.3.1 Service Region
10.7.3.2 PMG Name
10.7.3.3 PMG Number
10.7.3.4 Provider ID
10.7.3.5 Provider Name
PHYSICIAN INCENTIVE PLAN. DVHA may only operate a physician incentive plan if no specific payment can be made directly or indirectly under a physician incentive plan to a physician or physician group as an incentive to reduce or limit medically necessary services to a beneficiary.
PHYSICIAN INCENTIVE PLAN. The Contractor may, at its discretion, operate a Physician Incentive Plan (PIP) only if: • No single physician is put at financial risk for the costs of treating a Member that are outside the physician’s direct control; • No specific payment is made directly or indirectly to a physician or physician group as an inducement to reduce or limit medically appropriate services furnished to an individual Member; and, • The applicable stop/loss protection, Member survey, and disclosure requirements of 42 C.F.R. § 417 are met. The Contractor shall comply with all applicable requirements governing physician incentive plans, including but not limited to such requirements appearing at 42 C.F.R.§§ 422.208 and 422.210. In accordance with 42 C.F.R. § 438.6 (b), all incentive and withhold arrangements are necessary for the specified activities, targets, performance measures, or quality-based outcomes that support program initiatives as specified in the Department’s quality strategy. Performance for all incentive and withhold arrangements is measured during the rating period under which the incentive or withhold arrangement is applied. Further, all incentive and withhold arrangements must: • Be for a fixed amount of time; • Not be renewed automatically; • Be made available to both public and private contractors under the same terms of performance. • Does not condition MCO participation in the withhold arrangement on the MCO entering into or adhering to intergovernmental transfer agreements Additionally, the Contractor shall submit the Physician Incentive Plan annually to the Department. The Contractor shall be liable for any and all loss of Federal Financial Participation (FFP) incurred by the Department that results from the Contractor’s or any of its subcontractors’ failure to comply with the requirements governing physician incentive plans at 42 C.F.R.§§ 417, 434 and 1003; however, the Contractor shall not be liable for any loss of FFP under this provision that exceeds the total FFP reduction attributable to Members in the Contractor’s plan, and the Contractor shall not be liable if it can demonstrate, to the satisfaction of the Department, that it has made a good faith effort to comply with the cited requirements. The Contractor shall report biannually, or upon request, whether services not furnished by physician/group are covered by Physician Incentive Plan or incentive arrangement that includes withhold, bonus, capitation, and percent of withhold or bonus, if applica...
PHYSICIAN INCENTIVE PLAN. 8.5.1 The Contractor may establish physician incentive plans pursuant to federal and State regulations, including 42 CFR 422.208 and 422.210, and 42 CFR 438.6.
8.5.2 The Contractor shall disclose any and all such arrangements to DCH, and upon request, to Members. Such disclosure shall include:
PHYSICIAN INCENTIVE PLAN. A. If Contractor elects to operate a Physician Incentive Plan, Contractor agrees that no specific payment will be made directly or indirectly under the plan to a physician or physician group as an inducement to reduce or limit medically necessary services furnished to an Enrollee. Contractor agrees to submit to DHS annual reports containing the information on its physician incentive plan in accordance with 42 CFR § 438.6 (h). The contents of such reports shall comply with the requirements of 42 CFR §§ 422.208 and 422.210.
B. The Contractor must ensure that any contracts for contracted services covered by this contract, such as contracts between the Contractor and other entities or between the Contractor’s subcontracted entities and their contractors, at all levels including the physician level, include language requiring that the physician incentive plan information be provided by the subcontractor in an accurate and timely manner to the Contractor.
C. In the event that the incentive arrangements place the physician or physician group at risk for services beyond those provided directly by the physician or physician group for an amount beyond the risk threshold of twenty five percent (25%) of potential payments for covered services (substantial financial risk), the Contractor shall comply with all additional requirements listed in regulation, such as: conduct enrollee/disenrollee satisfaction surveys; disclose the requirements for the physician incentive plans to its beneficiaries upon request; and ensure that all physicians and physician groups at substantial financial risk have adequate stop-loss protection. Any of these additional requirements that are passed on to the subcontractors must be clearly stated in their contract.
PHYSICIAN INCENTIVE PLAN. First Medical may, upon prior written approval from ASES, design and implement a Physician Incentive Plan. First Medical shall submit a written request to ASES before implementing any such incentive program by providing a summary of the program for ASES review and approval at least sixty (60) Calendar Days before the projected implementation date for the program. XXXX has the absolute right to approve or disapprove the Physician Incentive program, and the program may be implemented only upon receipt of prior written approval from ASES. Once the Physician Incentive Plan is approved by ASES, First Medical shall notify applicable Physicians as established under section 7.1 of this Agreement.
11.12.1 The Physician Incentive Program shall contain the following requirements:
11.12.1.1 The program contains credible medical standards in support of the improvement of quality health services and reduces or eliminates any adverse effects on patients’ care;
11.12.1.2 All incentive payments to Providers are related to or made under quality initiatives supported or otherwise approved by CMS;
11.12.1.3 The implementation of the program in no way reduces or otherwise limits Enrollee Access to Medically Necessary Services (including a reduction in prescription drugs, diagnostic tests or treatments, hospitalization, and other treatment available regardless of the incentives);
