| Contracts | Types of Contracting | Integrated Delivery Systems | Miscellaneous and Ancillary | Potpourri |
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What is network
The common element for almost all managed care organizations – i.e. payers* – is a ______ that has contracts with many types of providers
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What is IPA?
___ model is the most common form of HMO today.
___ contracts with physicians, then with the health plan. Payment to ___ may or may not be the same as how ___ pays physicians |
What are Integrated Systems?
Truly _________ are those able to significantly improve quality & outcomes, and lower total cost of care
Generally refers to health systems that have integrated hospitals and physicians to some degree, and may involve other types of providers as well |
What are Therapeutic and Diagnostic?
A few examples of Ancillary Service Providers
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What are ambulatory facilities?
Example include surgical centers, urgent care centers, diagnostic imaging center.
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What are? Table of contents
Definitions Relationship of the parties Use of name Notification Insurance and indemnification Declarations, closing, etc. Term, often evergreen until notification For-cause reasons for suspension or termination
Name one or more contract elements
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What is MSO?
Often includes hospitals, but not always
Provide additional services beyond negotiation, e.g. Office support Medical management Billing and collection IT |
What is ACO?
At its heart, an ___ is a mechanism used to pay a type of provider organization in traditional FFS Medicare, and only traditional FFS Medicare, under the Medicare Shared Savings Program. A groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to their Medicare patients
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What is network adequacy?
Network adequacy or access standards refers to the ability of a member to receive care from a contracted provider on a reasonable basis
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What is Balance Billing?
The practice in which doctors or other health care providers bill you for charges that exceed the amount that will be reimbursed by Medicare for a particular service.
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What is Hold Harmless?
A contractual clause between a provider and payer that prohibits the provider from billing a member for charges associated with covered services, other than copayments, coinsurance and/or deductibles, even if the payer does not pay anything
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What are
Joint Commission (JCI) The Healthcare Facilities Accreditation Program (HFAP) Det Norske Veritas (DNV) Accreditation Association for Ambulatory Health Care (AAAHC) The American Association for Accreditation of Ambulatory Surgery Facilities Accreditation Program (AAAASF) The Community Health Accreditation Program (CHAP) The Accreditation Commission for Health Care (ACHC)
Name a Credentialing agency.
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What is Patient Centered Medical Home (PCMH)?
A model of care in which patients are engaged in a direct relationship with a chosen provider who coordinates a cooperative team of healthcare professionals, takes collective responsibility for the comprehensive integrated care provided to the patient, and advocates for the patient
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What are Hospital-Based Physicians?
Hospital-employed outpatient PCPs and specialist may be based in hospital, but ___ here only refers to those who’s focus in on inpatient and ED
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Who are: LSW, Podiatrist, Audiologists, etc.
Examples of Non-Physician Professionals who may Contract with Payers
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What are? Compliance with CM and UM programs
Maintenance of clinical standards, licensure, malpractice insurance, etc. Maintenance and retention of records Non-discrimination requirements Compliance with privacy and security requirements Acceptance of minimum number of patients from plan Compliance with certain administrative requirements such as timely billing, access to records, addressing patient/member complaints, etc. Compliance with Other Party Liability processes “Flow down” clauses and provider subcontracts for non-negotiable elements
Name a contract requirement required by law or regulation
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What is main body?
Elements that rarely change are in the ____ of the contract, such as descriptions of provider services covered and the health plan’s obligations
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What is Management services organization (MSO)?
___ are used primarily with independent physicians but may be used when physicians are indirectly employed or otherwise exclusive to the IDS. An ___ can also be combined with a GPWW or an IPA.
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What are? Demographics, Licenses and Other Identifiers
Liability insurance Graduation from medical school (any one of the following): Confirmation from the medical school American Medical Association Master File of Physicians in the United States Confirmation from the Association of American Medical Colleges Confirmation from the Educational Commission for Foreign Medical Graduates, for international medical graduates licensed after 1986. Confirmation from state licensure agency, if the agency performs primary verification of medical school graduation Valid license to practice medicine (any one of the following): State licensure agency Federation of State Medical Boards Primary admitting facility if the facility performs primary verification of licensure Current Professional Liability Insurance Policy Face Sheet DEA Registration Educational Commission for Foreign Medical Graduates (ECFMG) Certificate, if applicable State Controlled Dangerous Substance Certificate, if applicable State License Certificate Internal Revenue Service Form W-9: Request of Taxpayer Identification Number and Certification Worker’s Compensation Certificate of Coverage Curriculum Vitae US Department of Defence (DOD) DD214 Certificate of Release or Discharge from Active Duty, if applicable Visa, if applicable Specialty Board Certificate
A Few Basic Types of Required Physician Credentialing Information and Documentation
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What are appendices or attachments
Elements that change on a regular or semi-regular basis are only referenced in the main body of the contract and found in separate ________ or ________
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What is service area?
A plan’s ______ means the geographic area the plan meets its provider access requirements, at least for major types of providers
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What are Appendices?
Elements that change on a regular or semi-regular basis are only referenced in the main body of the contract and found in separate ____ or Attachments
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What are Physician-hospital organization (PHO)?
Used almost exclusively with independent physicians. The physicians may participate as individuals, medical groups, GPWWs, or some combination. Physicians may also participate solely through an IPA. _____ are not always true IDSs, though they can be.
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What is Vertically Integrated System?
A term that, if used at all, usually refers to an IDS that also offers a health plan. The system may own and operate the plan itself or it may be a partnership or joint venture with an existing payer.
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What is Surprise Billing?
____ happens when people unknowingly get care from providers that are outside of their health plan's network and can happen for both emergency and non-emergency care
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