Substantial Financial Risk. If the physician/group is put at substantial financial risk for services not provided by the physician/group, the Contractor shall ensure adequate stop-loss protection to individual physicians and conduct annual Enrollee surveys.
Substantial Financial Risk. If the provider/group is put at substantial financial risk for services not provided by the provider/group, the Contractor shall ensure adequate stop-loss protection to individual providers and conduct annual Enrollee surveys.
Substantial Financial Risk. A physician, or physician group as defined herein, is at substantial financial risk when more than twenty-five percent (25%) of the total maximum potential payments to the physician or physician group depend on the use of referral services. When the panel size is fewer than 25,000 enrollees, arrangements that cause substantial financial risk include, but are not limited to, the following:
7.9.3.1 Withholds greater than twenty-five percent (25%) of total potential payments.
7.9.3.2 Withholds less than twenty-five percent (25%) of total potential payments but the physician or physician group is potentially liable for more than twenty-five percent (25%) of total potential payments.
7.9.3.3 Bonuses greater than thirty-three percent (33%) of total potential payments, less the bonus.
7.9.3.4 Withholds plus bonuses if the withholds plus bonuses equal more than twenty-five percent (25%) of total potential payments.
7.9.3.5 Capitation arrangements if the difference between the minimum and maximum possible payments is more than twenty-five percent (25%) of the maximum possible payments, or the minimum and maximum possible payments are not clearly explained in the Contract.
Substantial Financial Risk. Pursuant to the guidelines put forth in 42 CFR 422.208, 422.210, and 438.6(h), if provider/group is put at substantial financial risk for services not provided by provider/group the PDHP must ensure adequate stop-loss protection to individual providers and conduct annual enrollee surveys.
Substantial Financial Risk. A physician, or physician group as defined herein, is at substantial financial risk when more than 25% of the total maximum potential payments to the physician or physician group depend on the use of referral services. When the panel size is fewer than 25,000 members arrangements that cause substantial financial risk include, but are not limited to, the following:
7.9.3.1. Withholds greater than 25% of total potential payments
7.9.3.2. Withholds less than 25% of total potential payments but the physician or physician group is potentially liable for more than 25% of total potential payments.
7.9.3.3. Bonuses greater than 33% of total potential payments, less the bonus.
7.9.3.4. Withholds plus bonuses if the withholds plus bonuses equal more than 25% of total potential payments.
7.9.3.5. Capitation arrangements if the difference between the minimum and maximum possible payments is more than 25% of the maximum possible payments, or the minimum and maximum possible payments are not clearly explained in the Contract.
