Substantial Financial Risk definition

Substantial Financial Risk means a physician or physician group as defined in this Section 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:

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.

Substantial Financial Risk means a physician or physician group as defined in this Section 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:

Examples of Substantial Financial Risk in a sentence

• Provider or provider groups are subject to requirements outlined in the Final Rule if determined to be at Substantial Financial Risk (SFR).

• As required by Exhibit H of the OHP Contract, if Subcontractor participates in a Practitioner Incentive Plan under the Agreement that places Subcontractor at Substantial Financial Risk, Subcontractor shall maintain PIP Stop-Loss Protection.

• PERSONAL ACCIDENT BENEFIT – OPTIONAL BENEFITExceptionsProvided always that The Company shall not be liable under this Policy for:1.

• For any subcontractor at financial risk, as defined in the Substantial Financial Risk provision, or of the Risk provision found in the Definitions Section of this Contract, the Contractor shall establish, enforce and monitor solvency requirements that provide assurance of the subcontractor's ability to meet its obligations.

• The Net Aggregate Savings will be limited by the Substantial Financial Risk Limit of 25% to determine final Net Aggregate Savings payment amounts.Shared savings cannot exceed the Substantial Financial Risk Limit.

• Substantial Financial Risk – An incentive arrangement based on referral services that place the physician or physician group at risk for amounts beyond the risk threshold.

• If Provider has agreed to provide medical service to a Member for a capitation payment, fixed fee, or other arrangement that imposes Substantial Financial Risk on Provider, Provider must protect itself against loss by maintaining a stop loss protection as required by 42 CFR 422.208 and 422.210 (“Physician Incentive Plan Regulations”) and the CCO Contract.

• To estimate the impact of the provider group’s savings payout relative to their Substantial Financial Risk Limit, each group’s shared savings payout is divided by its annual paid dollars received from Anthem.

• The Shared Savings Potential percent shown in this MA Measurement Period Handbook is subject to the performance adjustments described in this Program Description and in the MA Measurement Period Handbook.• Substantial Financial Risk Limit.

• Substantial Financial Risk, for purposes of this section, means risk for referral services that exceeds the risk threshold.Withhold means a percentage of payments or set dollar amounts deducted from a physician’s service fee, capitation, or salary payment, and that may or may not be returned to the physician, depending on specific predetermined factors.

More Definitions of Substantial Financial Risk

Substantial Financial Risk has the meaning specified in 42 C.F.R. (S)417.479, -------------------------- as amended from time to time.

Substantial Financial Risk means financial risk achieved through capitation or the creation of significant financial incentives for the group to achieve specified cost- containment goals, such as withholding from all members a substantial amount of the compensation due to them, with distribution of that amount to the members or owners only if the cost-containment goals are met.

Substantial Financial Risk means financial risk such as that achieved when an organization receives revenue through capitation or payment of insurance premiums, or when the organization creates significant financial incentives for providers to achieve specified cost-containment goals, such as withholding a substantial amount of their compensation, with distribution of that amount made only if the cost-containment goals are met.

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.