Submitted by: Submitted by Skhimel
Views: 58
Words: 1943
Pages: 8
Category: Business and Industry
Date Submitted: 02/18/2015 05:37 AM
Requirements for physician incentive plans.
(a) The contract must specify that an HMO or CMP may
operate a physician incentive plan only if—
(1) No specific payment is made directly or indirectly
under the plan to a physician or physician group as an
inducement to reduce or limit medically necessary
services furnished to an individual enrollee; and
(2) The stop-loss protection, enrollee survey, and
disclosure requirements of this section are met.
(b) Applicability. The requirements in this section apply to
physician incentive plans between HMOs and CMP and
individual physicians or physician groups with which they
contract to provide medical services to enrollees. The
requirements in this section also apply to subcontracting
arrangements as specified in § 417.479(i) . These
requirements apply only to physician incentive plans that
base compensation (in whole or in part) on the use or cost
of services furnished to Medicare beneficiaries or Medicaid
beneficiaries.
(c) Definitions. For purposes of this section:
Bonus means a payment an HMO or CMP makes to a
physician or physician group beyond any salary, fee-for-
service payments, capitation, or returned withhold.
Capitation means a set dollar payment per patient per unit of
time (usually per month) that an organization pays a
physician or physician group to cover a specified set of
services and administrative costs without regard to the
actual number of services provided. The services covered
may include the physician's own services, referral services,
or all medical services.
Payments means any amounts the HMO or CMP pays
physicians or physician groups for services they furnish
directly, plus amounts paid for administration and amounts
paid (in whole or in part) based on use and costs of referral
services (such as withhold amounts, bonuses based on
referral levels, and any other compensation to the physician
or physician group to influence the use of referral services).
Bonuses...