Provider Incentives. (2 pages, plus 1 additional page per additional MCO Program bid if the Respondent’s response differs by MCO Program) The Respondent must submit a proposal for a pilot “gain sharing” program. The program should focus on collaborating with Network physicians and Hospitals in order to allow them to share a portion of the Respondent’s savings resulting from reducing inappropriate utilization of services, including inappropriate admissions and readmissions. The proposal should include mechanisms whereby the Respondent will provide incentive payments to Hospitals and physicians for quality care. The proposal should include quality metrics required for incentives, recruitment strategies of providers, and a proposed structure for payment.
Provider Incentives. The MCO will conduct a pilot “gain sharing” program, subject to HHSC’s approval. The program will focus on collaborating with Network physicians and Hospitals in order to allow them to share a portion of the MCO’s savings resulting from reducing inappropriate utilization of services, including inappropriate admissions and readmissions. The program will include mechanisms whereby the MCO will provide incentive payments to Hospitals and physicians for quality care. The program will include quality metrics required for incentives, recruitment strategies of providers, and a proposed structure for payment.
Provider Incentives. The MCO must develop and submit to HHSC a written plan using a form provided by HHSC, for expansion of alternative payment structures with its Providers that encourages innovation and collaboration, as well as increase quality and efficiency. Payment structures should be focused on incentivizing quality outcomes, shared savings, or both resulting from reducing inappropriate utilization of services, including inappropriate admissions and readmissions rather than based on volume. The plan will include mechanisms by which the MCO will provide incentive payments to hospitals, physicians and other health care providers for quality care. The plan will include quality metrics required for incentives, recruitment strategies of providers, and a proposed structure for incentive payments, shared savings, or both. The MCO must submit its initial plan to HHSC no later than December 1, 2013, and no later than December 1 of each year thereafter. HHSC will evaluate the plan and provide feedback to the MCO. Upon HHSC's approval of the plan, HHSC will retrospectively evaluate the MCO on its execution of the written plan. Modifications can be made to the plan, but are subject to HHSC review and approval. Plan approval is based on the following criteria: the number of providers, diversity of selected providers, geographic representation, and the methodology of the shared savings, data sharing strategy with providers, and other factors. Each year, the annual plan must show a measurable increase from the previous year. HHSC's retrospective review of the execution of the plan may include a review of encounter data, MCO financial statistical reports, and surveys or interviews with MCO representatives or providers. HHSC may ask the MCO to submit additional information upon request. HHSC may delay or reduce payments to the MCO if it does not submit a plan by the required deadline or does not execute a plan as approved.
Provider Incentives. Appeals Process for Senior Plan Members......................... 11.16 Notices......................................................... 11.17
Provider Incentives. Both PacifiCare and the DENTIST understand ------------------- and agree that any payments made directly or indirectly to the DENTIST under any DENTIST incentive provisions set forth in this Agreement are not made as an inducement to reduce or limit dentally necessary services to any specific PacifiCare Member.
