Common use of Provider Compensation Clause in Contracts

Provider Compensation. a. The MCO shall comply with HCFA's Physician Incentive Plan (PIP) requirements in 42 CFR 434.70. The MCO may operate a PIP only if: 1. no specific payment can be made directly or indirectly under a PIP to a physician or physician group as an inducement to reduce or limit medically necessary services furnished to an individual Member; and 2. the stop-loss protection, Member survey, and disclosure requirements of 42 C.F.R. 417.479 are met. b. The MCO shall disclose to the DEPARTMENT the following information on PIPs in sufficient detail to determine whether the incentive plan complies with the regulatory requirements of 42 CFR 417.479. The disclosure must contain: 1. Whether services not furnished by the physician or physician group are covered by the PIP. If only the services furnished by the physician or physician group are covered by the incentive plan, disclosure of other aspects of the plan need not be made. 2. The type of incentive arrangement (i.e. withhold, bonus, capitation). 3. If the incentive plan involves a withhold or bonus, the percent of the withhold or bonus. 4. Proof that the physician or physician group has adequate stop-loss protection, including the amount and type of stop-loss protection. 5. The panel size and, if patients are pooled, the method used. 6. In the case of those MCOs that are required by 42 C.F.R. 417.479 provision to conduct Member surveys, the survey results. c. The MCO shall disclose this information to the DEPARTMENT (1) prior to approval of its contract as required by federal regulation and (2) upon the contract anniversary or renewal effective date. The MCO shall provide the capitation data required (see (6) above) for the previous contract year to the DEPARTMENT three (3) months after the end of the contract year. The MCO will provide to the Member upon request information regarding whether the MCO uses a physician incentive plan that affects the use of referral services, the type of incentive arrangement, whether stop-loss protection is provided, and the survey results of any Member survey conducted. See Appendix J for the applicable regulations and disclosure forms. d. The DEPARTMENT may impose Class C sanctions pursuant to Section 7.05 for failure to comply with 42 C.F.R. 417.479

Provider Compensation. a. The MCO shall comply with HCFACMS's Physician Incentive Plan (PIP) requirements in 42 CFR 434.70422.208 and 42 CFR 422.210. The MCO may operate a PIP only if: 1. no No specific payment can be made directly or indirectly under a PIP to a physician or physician group as an inducement to reduce or limit medically necessary services furnished to an individual Member; and 2. the The stop-loss protection, Member survey, and disclosure requirements of 42 C.F.R. 417.479 CFR. 422.208 and 42 CFR 422.210 are met. b. The MCO shall disclose to the DEPARTMENT the following information on PIPs in sufficient detail to determine whether the incentive plan complies with the regulatory requirements of 42 CFR 417.479422.208. The disclosure must contain: 1. Whether services not furnished by the physician or physician group are covered by the PIP. If only the services furnished by the physician or physician group are covered by the incentive plan, disclosure of other aspects of the plan need not be made. 2. The type of incentive arrangement (i.e. withhold, bonus, capitation). 3. If The percent of the withhold or bonus if the incentive plan involves a withhold or bonus, the percent of the withhold or bonus,. 4. Proof that the physician or physician group has adequate stop-loss protection, including the amount and type of stop-loss protection. 5. The panel size and, if patients are pooled, the method used. 6. In the case of those MCOs that are required by 42 C.F.R. 417.479 provision CFR. 422.208(h) to conduct Member surveys, the survey results. c. The MCO shall disclose this information to the DEPARTMENT (1) prior to approval of its contract as required by federal regulation and (2) upon the contract anniversary or renewal effective date. The MCO shall provide the capitation data required (see (6) above) for the previous contract year to the DEPARTMENT three (3) months after the end of the contract year. The MCO will provide to the Member upon request information regarding whether the MCO uses a physician incentive plan that affects the use of referral services, the type of incentive arrangement, whether stop-loss protection is provided, and the survey results of any Member survey conducted. See Appendix J for the applicable regulations and disclosure forms. d. The DEPARTMENT may impose Class C sanctions pursuant to Section 7.05 for failure to comply with 42 C.F.R. 417.479CFR 422.208 and 422.210