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:

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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 specific 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.

Examples of Substantial Financial Risk in a sentence

Provider must disclose annually to Health Plan and Subcontractor any PIP or risk arrangements Provider may have with physicians either within its group practice or other physicians not associated with the group practice even if there is no Substantial Financial Risk between Health Plan or Subcontractor and the physician or physician group.
To the extent either Practitioner or any person/entity with which Practitioner contracts utilizes a Physician Incentive Plan that places individual physicians or a physician group at Substantial Financial Risk as described in 42 C.F.R. § 417.479, then Practitioner shall ensure that adequate stop-loss insurance has been obtained pursuant to 42 C.F.R. § 417.479.
Practitioner shall notify the Plan at least sixty (60) days in advance of implementation by Practitioner or any person/entity with which Practitioner contracts of any Practitioner Incentive Plan which would place individual physicians at Substantial Financial Risk and the parties shall ensure compliance with this section.
PH-MCOs that have PIPs placing a physician or physician group at Substantial Financial Risk for the cost of services the physician or physician group does not furnish must assure that the physician or physician group has adequate Stop-Loss Protection.
PH-MCOs that have PIPs placing a physician or physician group at Substantial Financial Risk for the cost of service the physician or physician group does not furnish must also conduct surveys of Members and disenrollees addressing their satisfaction with the quality of services and their ability to access services.
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.
For any subcontractor at financial risk, as described in Section 8.8.3. Substantial Financial Risk, or Section 1.17.
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.
Substantial Financial Risk — 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.
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.

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 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.

Substantial Financial Risk is determined by the following calculation: Referral Risk = Amount at risk for referral services Maximum potential payments