Common use of INSTITUTIONAL PROVIDERS Clause in Contracts

INSTITUTIONAL PROVIDERS. Hospitals For most Inpatient medical and surgical Covered Services, Hospitals are paid per diem rates, which are specific amounts paid for each day a Member is in the Hospital. These rates usually vary according to the intensity of services provided and do not typically include any payment for professional (e.g., physician/surgeon) charges or expenses. Some Hospitals are also paid case rates, which are set dollar amounts paid for a complete Hospital stay related to a specific procedure or diagnosis, (e.g., transplants). For most outpatient and Emergency Covered Services and procedures, most Hospitals are paid specific rates based on the type of service performed. Hospitals may also be paid a global rate for certain outpatient Covered Services (e.g., lab and radiology) that includes both the Facility (or a technical charge) and Physician payment. For a few Covered Services, Hospitals are paid based on a percentage of their billed charges. Most Hospitals are paid through some combination of the above payment mechanisms for various Covered Services. Some Hospitals participate in a quality incentive program. The program provides increased reimbursement to these Hospitals when they meet specific quality and other criteria, including "Patient Safety Measures". Such patient safety measures may include and are consistent with recommendations by CMS, The Leap Frog Group, Joint Commission on Accreditation of Health care Organizations (JCAHO), and the Agency for Health Care Research and Quality (AHRQ). The quality criteria are designed to help reduce medical and medication errors. Other criteria are directed at improved patient outcomes and electronic claim and record submissions. Use of these types of incentives is expected to evolve over time. Skilled Nursing Homes, Rehabilitation Hospitals, and other care facilities Most Skilled Nursing Facilities and other special care facilities are paid per diem rates, which are specific amounts paid for each day a Member is in the facility and do not typically include any payment to the facility for professional (e.g., physician) charges or expenses. These amounts may vary according to the intensity of services provided. Ambulatory Surgical Centers (ASCs) Most ASCs are paid specific rates based on the type of service performed. For a few Covered Services, some ASCs are paid based on a percentage of its billed charges. Ancillary Service Providers Some ancillary service providers, such as Durable Medical Equipment and Home Health Care Providers, are paid fee-for-service payments according to our HMO fee schedule for the specific medical services performed. Other ancillary service providers, such as those providing laboratory, dental and vision Covered Services, may be paid per Member per month amount for each Member or may be paid on a fee-for-service basis. Capitated ancillary service vendors are responsible for paying their contracted providers and do so on a fee-for-service basis. Behavioral Health Services Keystone contracts with a behavioral health management company which provides a network of participating behavioral health providers and is paid on a per Member per month amount (capitation) for each Member. This company pays its affiliated providers on a fee-for-service basis.