Incentive arrangements prohibited that induce limitation of services Under federal regulations, Medica, through its contracts with the Centers for Medicare & Medicaid Services (CMS) and the Minnesota Department of Human Services (DHS) to service Medicare and Medicaid enrollees, is prohibited from having incentive arrangements with physicians that act as inducements to physicians to withhold or limit medically necessary services to specific enrollees.
PIP requirements relate to CMS’s assurance that enrollees have access to medically necessary referral services. CMS uses the required PIP data to monitor compliance with federal statutes and supporting regulations governing physician incentives through Medicare and Medicaid managed care organizations.
PIP arrangements may be in place directly through the contract Medica holds with the clinic or indirectly through subcontracts (physician compensation plans with their affiliated clinic). Under the PIP regulations, if physicians are put at “substantial financial risk” by any incentive arrangements the clinic may have with them, there must be adequate stop-loss protection.
Medica is also required to conduct member satisfaction surveys and supply these results to regulators and members upon their request.
Clinics only need to submit information to Medica if information has changes or, if newly contracted with Medica, to submit first-time information to Medica. To update or initially submit information, clinic providers are required to use the CMS form titled “Physician Incentive Plan Summary Data Form for Providers” to gather and update the information and then return this form to Medica withing 30 days of a change in the provider reimbursement structure. There are two options for returning completed forms to Medica by:
- Fax at 952-992-8355
- U.S. mail to:
Medica - Network Management
C/O Physician Incentive Plans (PIP)
Maile Route 80030
PO Box 9310
Minneapolis, MN 55440-9310
The Physician Incentive Plan Summary Data Form for Providers is available on the CMS Web site. Otherwise, hard copies of the form may be requested by calling Medica’s Provider Literature Request Line. For further information regarding physician incentive plans, providers may contact their Medica contract manager.
Download Physician Incentive Plan Summary Data Form. [link doesn't work]
http://www.cms.hhs.gov/healthplans/pip/01dfm_1.pdf.
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