Physician Incentives. The Contractor must comply with all applicable physician incentive requirements and conditions defined in 42 CFR 417.479. These regulations prohibit physician incentive plans that directly or indirectly make payments to a doctor or a group an inducement to limit or refuse medically necessary services to a member. The Contractor is required to disclose all physician incentive agreements to CPSA and to enrolled persons who request them. The Contractor shall not enter into contractual arrangements that place providers at significant financial risk as defined in CFR 417.479 unless specifically approved in advance by CPSA. In order to obtain approval, the following must be submitted to CPSA 90 days prior to the implementation of the subcontract:
Physician Incentives. Provider shall disclose to ACIA annually any Physician Incentive Plan (PIP) or risk arrangements Provider may have with physicians, either within Provider’s group practice or other physicians not associated with Provider’s group practice, even if there is no substantial financial risk between ACIA and the physician or physician group. The term “substantial financial risk” means a financial risk set at greater than twenty-five percent (25%) of potential payments for Covered Services, regardless of the frequency of assessment (i.e., collection) or distribution of payments. The term “potential payments” means simply the maximum anticipated total payments that the physician or physician group could receive if the use or cost of referral services were significantly low. 42 CFR §§438.6(g), 422.208, 422.210. Provider Discrimination Prohibited. ACIA may not, with respect to Provider compensation or indemnification under this Agreement, discriminate against Provider to the extent that the Provider is acting within the scope of his, her or its license or certification under applicable State law, solely on the basis of that license or certification. Without limiting the foregoing, ACIA shall not discriminate against Provider for serving high-risk populations or specializing in conditions that require costly treatment. Nothing herein shall be construed to: (i) require ACIA to contract with Provider if not necessary to meet the needs of Members; (ii) preclude ACIA from using different reimbursement amounts for different specialties or for different practitioners in the same specialty; or (iii) preclude ACIA from establishing measures that are designed to maintain quality of services and control costs and are consistent with ACIA’s responsibilities to Members. 42 CFR §438.12.
Physician Incentives. Hospital shall disclose to ACOH annually any Physician Incentive Plan (PIP) or risk arrangements Hospital may have with physicians, either within Hospital’s group practice or other physicians not associated with Hospital’s group practice, even if there is no substantial financial risk between ACOH and the physician or physician group. The term
Physician Incentives. Hospital shall disclose to ACDE annually any Physician Incentive Plan (PIP) or risk arrangements Hospital may have with physicians, either within Hospital’s group practice or other physicians not associated with Hospital’s group practice, even if there is no substantial financial risk between ACDE and the physician or physician group. The term “substantial financial risk” means a financial risk set at greater than twenty-five percent (25%) of potential payments for Covered Services, regardless of the frequency of assessment (i.e., collection) or distribution of payments. The term “potential payments” means simply the maximum anticipated total payments that the physician or physician group could receive if the use or cost of referral services were significantly low. 42 CFR §§438.3(i), 422.208, 422.210.
Physician Incentives. Provider shall disclose to ACOH annually any Physician Incentive Plan (PIP) or risk arrangements Provider may have with physicians, either within Provider’s group practice or other physicians not associated with Provider’s group practice, even if there is no substantial financial risk between ACOH and the physician or physician group. The term “substantial financial risk” means a financial risk set at greater than twenty-five percent (25%) of potential payments for Covered Services, regardless of the frequency of assessment (i.e., collection) or distribution of payments. The term “potential payments” means simply the maximum anticipated total payments that the physician or physician group could receive if the use or cost of referral services were significantly low. 42 CFR §§438.3(i), 422.208, 422.210.
