Quality Programs. Claims incurred by Enrollees include amounts that BCN reimburses health care providers, including reimbursement tied to value in accordance with “Quality Programs,” which are governed by separate agreements with health care providers and are designed to improve health care outcomes and control health care costs. BCN has adopted a provider payment model that includes both fee-based and value-based reimbursement. BCN does not unbundle claims and does not retain any component of claims as compensation. BCN negotiates provider reimbursement rates on its own behalf and makes those rates available to customers through its products and networks. The reimbursement rates can, and often do, vary from provider to provider. Providers may qualify for higher reimbursement rates for satisfying requirements of certain BCN Quality Programs, including, for example, Pay-for-Performance rates and Value Based Contracting rates earned by hospitals and Patient Centered Medical Home rates earned by physicians. Providers may also receive reward and incentive payments from BCN Quality Programs funded through an allocation from provider reimbursement or other agreed upon methods. Such allocations may be to a pooled fund from which value-based payments to providers are made. For example, pursuant to the Physician Group Incentive Program (PGIP), physicians agree to allocate a percentage of each claim to a PGIP fund, which in turn makes reward payments to eligible physician organizations demonstrating particular quality and pays physician organizations for participation in collaborative initiates. Provider reimbursement rates also capture provider commitments to BCN Quality Programs. For example, hospitals participating in Hospital Collaborative Quality Initiatives agree to allocate a portion of their reimbursement to fund inter-hospital quality initiatives. Value based reimbursement includes other obligations and entitlements pursuant to other Quality Programs funded in a similar manner to those described above. Additional information is available from BCN account representatives and at xxx.xxxxxxxxxxxxxxxxx.xxx.
Quality Programs. Section 1
Quality Programs. Preferred Provider will participate in and abide by the decisions of all quality assurance, utilization review, and Member complaint and grievance systems applicable to Managed Care Plans.
Quality Programs. Section 1 - Introduction Both parties recognize the importance of a strong commitment to comprehensive quality programs in the Department. Service to the veteran is the cornerstone of the relationship between the Department and employees. Both parties agree that a successful quality program must empower all employees to fully participate in the development and implementation of Department programs and processes. The Department recognizes the Union as the exclusive bargaining unit representative in implementing, maintaining, and improving these quality programs. Participation of bargaining unit employees in the Department’s quality programs is a matter left to the discretion of the Union in its role on the facility Quality Council.
Quality Programs. Government Sponsored Programs Provider will participate in and abide by the decisions of all quality assurance, utilization review, and Member complaint and grievance systems applicable to Managed Care Plans.
Quality Programs. Professional Provider will participate in and abide by the decisions of all quality assurance and improvement, utilization review, or management, and Member complaint, grievance and external appeal systems applicable to Act 146 Product(s).
