Prohibitions on Inappropriate Physician Incentives. The MCO must comply with regulatory requirements regarding physician incentives as specified in 42 CFR 417.479, 42 CFR 438.6(h), 42 CFR 422.208, and 42 CFR 422.210. The MCO may not make specific payment, directly or indirectly, to a physician or physician group as an inducement to reduce or limit Medically Necessary covered services furnished to any particular enrollee. Indirect payments may include offerings of monetary value (such as stock options or waivers of debt) measured in the present or future. As specified in 42 CFR 417.479, MCOs that operate physician incentive plans that place physicians or physician groups at substantial financial risk must conduct enrollee surveys. These surveys must include either all current Medicaid enrollees in the MCO and those who have disenrolled (other than because of loss of eligibility or relocation outside the MCO’s service area) in the past twelve (12) months, or a statistically valid sample of these same enrollees and disenrollees. The surveys must address enrollee/disenrollee satisfaction with the quality of services provided and the accessibility of the services and must be conducted on an annual basis. The MCO must collect the following information annually and make it available to BMS and CMS upon request, within ten (10) working days. • Whether services not furnished by the physician or physician group are covered by the incentive plan. • The type or types of incentive arrangements, such as bonus, capitation. • The percent of any bonus the plan uses. • Assurance that the physicians or physician group has adequate stop-loss protection, and the amount and type of stop-loss protection. • The patient panel size and, if the plan uses pooling, the pooling method. • If the MCO is required to conduct enrollee/disenrollee surveys, provide a summary of the survey results to BMS and, upon request, to enrollees. • Information on the physician incentive plan to enrollees, upon request. The MCO must comply with any additional rules regarding physician incentives released by CMS.
Prohibitions on Inappropriate Physician Incentives. The MCO must comply with regulatory requirements regarding physician incentives as specified in 42 CFR 417.479, 42 CFR 438.6(h), 42 CFR 422.208, and 42 CFR 422.210. The MCO may not make specific payment, directly or indirectly, to a physician or physician group as an inducement to reduce or limit Medically Necessary covered services furnished to any particular enrollee. Indirect payments may include offerings of monetary value (such as stock options or waivers of debt) measured in the present or future. As specified in 42 CFR 417.479, MCOs that operate physician incentive plans that place physicians or physician groups at substantial financial risk must conduct enrollee surveys. These surveys must include either all current Medicaid enrollees in the MCO and those who have disenrolled (other than because of loss of eligibility or relocation outside the MCO’s service area) in the past 12 months, or a statistically valid sample of these same enrollees and
