"ALL SECTIONS MARKED WITH TWO ASTERISKS ("**") REFLECT PORTIONS WHICH HAVE
BEEN REDACTED AND FILED SEPARATELY WITH THE SECURITIES AND EXCHANGE
COMMISSION BY PROSPECT MEDICAL HOLDINGS, INC. AS PART OF A REQUEST FOR
CONFIDENTIAL TREATMENT."
1992 AMENDMENT TO
IPA MEDICARE SHARED RISK SERVICES AGREEMENT
The Undersigned parties to the PacifiCare IPA Medicare Partial Risk Services
Agreement between PacifiCare of California ("PacifiCare") and Santa
Xxx-Tustin Physician's Group, Inc. ("IPA") do hereby amend said Agreement as
follows:
1. Paragraph 1.03 is amended to read as follows:
1.03 CATASTROPHIC CASE - is any single medical condition, including
complications arising from such medical condition, where the total cost of
Health Care Services to treat such condition is expected to exceed [ ** ]
per condition, regardless of payment source.
2. Paragraph 3.02 is amended in full to read as follows:
3.02 STANDARDS - All Medical Services arranged for or provided by IPA
and its Member Physicians shall be provided by professional personnel and at
physical facilities according to generally accepted standards of medical
practice and management in the community. IPA further agrees to provide or
arrange for Referrals to Specialist Physicians and facilities as are
necessary, appropriate, and in accordance with generally accepted standards of
medical practice in the community in compliance with the standards developed
by PacifiCare's Quality Assurance Committee. If IPA contracts with Specialist
Physicians to provide Medical Services under this Agreement, IPA shall
require such Specialist Physicians to provide IPA with the credentialing
information set forth herein. IPA shall obtain and maintain information
concerning each Member Physician's and Specialist Physician's education,
training, references, malpractice liability insurance, hospital staff status,
hospital clinical privileges, and hospital staff reappointment dates. Such
information shall be kept in a form prescribed by or acceptable to
PacifiCare. Upon request, the credentialing information shall be made
available to PacifiCare for review or copying.
IPA acknowledges and agrees that it shall report Member Physicians or
Specialist Physicians as required by the California Business and Professions
Code Section 805 ("Section 805"). IPA further agrees to maintain and
demonstrate to PacifiCare upon request compliance with the following:
3.02.01 IPA shall use best efforts to ensure that its Member Physicians
and Specialist Physicians are licensed by the State of California and have
current Drug Enforcement Agency ("DEA") registration. IPA shall immediately
notify PacifiCare in writing of any of the following actions taken by or
against a Member
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Physician or Specialist Physician: (i) the surrendering, revocation, or
suspension of a license; (ii) the surrendering, revocations, or suspension of
current DEA registration; (iii) any filing pursuant to Section 805; (iv) any
filing pursuant to the National Practitioner Data Bank; (v) the filing of
any malpractice claim of more than ten thousand dollars ($10,000); and (vi)
a change in hospital staff status or hospital clinical privileges, including
any restrictions or limitations.
3.02.02 In the event that it is determined by PacifiCare that IPA does
not obtain and maintain the information set forth in paragraph 3.02, IPA
agrees to assist PacifiCare in obtaining credentialing information concerning
each Member Physician's and Specialist Physician's education, training,
references, malpractice liability insurance, hospital staff status, hospital
clinical privileges, and hospital staff reappointment dates. IPA shall
obtain from each Member Physician and Specialist Physician a signed waiver,
acceptable to PacifiCare, allowing PacifiCare access to such credentialing
information at any acute care hospital or health care facility. If IPA is
unable to obtain a signed waiver from a Member Physician or Specialist
Physician, IPA shall obtain the credentialing information directly from the
acute care hospital or health care facility and make such information
available to PacifiCare upon request for review and copying.
3.02.03 IPA agrees to provide access to continuing education programs
for its Member Physicians and Specialist Physicians in accordance with the
standards established by the California Medical Association for continuing
education. The content and delivery of such continuing education programs
shall be in the discretion and judgement of IPA, in order to maintain high
standards for the delivery of Medical Services pursuant to this Agreement.
IPA further agrees to gather, correlate, and distribute to its Member
Physicians and Specialist Physicians, information regarding professional
medical activities and developments which IPA believes may be of assistance
in providing Medical Services pursuant to this Agreement.
3.02.04 IPA agrees to provide reasonable evidence that all nurses and
other ancillary and paramedical personnel who are employed by and contract
with IPA or Specialist Physicians are properly licensed by the State of
California.
3. Paragraph 5.02 is amended to read as follows:
5.02 ADDITIONAL PAYMENTS - Pacificare and IPA agree to provide
payments to each other in accordance with the terms of the following
programs, if applicable: Hospital Incentive Program, Individual Stop-Loss
Program, Benefit Withhold Incentive Program and Mammography Reimbursement
Program as specified in Attachments A5, A3, E and C respectively,
incorporated in full herein by
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reference.
To the extent that each party owes an amount to the other party in the risk
programs noted above, IPA agrees that PacifiCare shall combine the results of
all applicable risk programs such that one aggregate payment is payable to or
receivable from IPA. A fully detailed accounting of the results of each
program shall accompany the aggregate payment or notice of amount due.
4. Attachment A4 COST OF CARE - is amended in part to read as follows:
For purposes of this Agreement, the Cost of Care for Medical Services
rendered by IPA to Subscriber shall equal:
a) [ ** ] of the fees charged by IPA to IPA's fee-for-service patients
for the same or similar services, if the same or similar services are
rendered by Member Physicians who practice at IPA Facilities; or
b) [ ** ] of the fees actually paid, if the services are rendered by
Specialist Physicians or Outside Providers.
5. Attachment A5 HOSPITAL INCENTIVE PROGRAM is amended in part to read as
follows:
b. HOSPITAL SERVICES BUDGET - The Hospital Services Budget shall equal
[ ** ] of the Monthly HCFA Payment for those Subscribers designating IPA as
their Participating Medical Group, minus [ ** ] of such HCFA Payment in
consideration of the Reinsurance Program as set forth in subsection (c)(4)
herein.
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The effective date of this Amendment is January 1, 1992
By signing below, both parties hereto have executed and agreed to this
Amendment.
PACIFICARE, INC IPA
By: /s/ Xxxxx Xxxxxxx BY: /s/ Xxxxxx Xxxxx
-------------------------------- ----------------------------
Xxxxx Xxxxxxx, Vice President
Date: 7/18/93 Date: 6/28/93
------------------------------- ---------------------------
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EXHIBIT A
ATTACHMENT A
Payment Rates
Tustin Hospital Medical Center
For Santa Xxx Xxxxxx Physicians Medical Group
Hospital and Emergency Services provided pursuant to this Agreement shall be
reimbursed at the rates described below effective 9-1-92:
LEVEL OF SERVICE PER DIEM RATES
A. Acute Medical/Surgical $ [ ** ]
ICU/CCU $ [ ** ]
Detox Adult and Adolescent $ [ ** ]
Rehab Adult and Adolescent $ [ ** ]
Sub Acute (includes 2 Hours rehab) $ [ ** ]
Day Treatment $ [ ** ]
STOPLOSS: If total billed charges for a patient's stay equals or exceeds
[ ** ], reimbursement shall be at the above per diems up to stop loss limit
and [ ** ] of billed charges for those charges in excess of the stop loss
limit.
B. In the case of authorized emergency room or outpatient
Hospital Services, or services not listed above utilized by
PacifiCare Subscribers, Hospital agrees to accept [ ** ]
of Hospital's usual and customary rates, less any Copayments
collected.
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PAYMENT RATES
Tustin Hospital Medical Center
For all Secure Horizons And Pacificare Members
A. In the case of Hospital Services, Emergency Services and
Outpatient Hospital Services utilized by PacifiCare Subscribers,
Hospital agrees to accept [ ** ] of Hospital's usual and
customary rates, less any Copayments collected.
B. In the case of Hospital Services utilized by Secure Horizons
Subscribers, Hospital agrees to accept [ ** ] for the stay
and [ ** ] of Hospital's usual and customary rates, less any
Copayments collected, for Emergency and Outpatient Services.
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