AGREEMENT FOR PATIENT-CENTERED MEDICAL HOME (PCMH 2014) RECOGNITION PROGRAM (the Agreement )

Transcription

1 AGREEMENT FOR PATIENT-CENTERED MEDICAL HOME (PCMH 2014) RECOGNITION PROGRAM (the Agreement ) The National Committee for Quality Assurance ( NCQA ), located at th Street, N.W., Suite 1000, Washington, D.C , and the individual or entity designated below whose electronic signature is submitted as evidence of agreement to these terms hereinafter referred to as ( Practice ), for good and valuable consideration, hereby agree as follows: 1. Practice certifies that, to the best of its knowledge and belief, the information submitted for survey under the Patient-Centered Medical Home (PCMH 2014) Program is correct, was obtained using procedures specified in the PCMH 2014 Survey Tool and PCMH 2014 Policies and Procedures. Practice agrees to promptly notify NCQA of any material changes in the information provided to NCQA under the PCMH 2014 Program. Practice agrees to make available to NCQA, PCMH 2014 surveyors, auditors, PCMH 2014 Review Oversight Committee and PCMH 2014 Reconsideration Committee information that would verify what appears in the application materials and PCMH 2014 Survey Tool. Further, the Practice agrees that NCQA may make available to an NCQA Certified credentialing verification organization(s) licensure and other information that NCQA wishes to verify for purposes of reaching a recognition decision under the PCMH 2014 Program. If recognized under the PCMH 2014 Program, Practice agrees to submit to discretionary reviews and any annual performance reporting as deemed necessary by NCQA. 2. Surveys under the PCMH 2014 Program are subject to the fees in effect when Practice applies for recognition under the PCMH 2014 Program, as identified in Exhibit A, which is attached to and incorporated by reference into this Agreement. 3. Practice agrees, in addition to its obligations under this Agreement, to abide by and be bound by all PCMH 2014 policies, procedures, rules and regulations pertaining to the PCMH 2014 Program, including but not limited to the PCMH 2014 Policies and Procedures provided with the application and updated from time to time. Applicants will be notified of material changes and their effective date via and Web site postings. If recognition under the PCMH 2014 Program results in monetary rewards from purchasers, plans or others tied to quality, Practice understands and agrees that NCQA neither recommends nor decides whether or to what extent Practice should or will receive such rewards. 4. Practice and NCQA agree that NCQA may publish on its Web site or in other formats, and authorize others to publish, that Practice has achieved recognition under the PCMH 2014 Program and which recognition level the practice achieved. NCQA reserves the right to release and to publish, and authorize others to publish, results of the practice s performance under specific standards, elements, factors and reporting categories. If Practice does not achieve recognition under the PCMH 2014 Program, NCQA will not publicly report that result or authorize others to publicly report that result. Practice acknowledges and agrees that NCQA reserves the right to de-identify or aggregate the physician and practice site data NCQA PCMH (FINAL ver ) 1

2 submitted as part of the PCMH 2014 Program, and to utilize these de-identified or aggregated data for research by NCQA, to authorize others to use such data for research, and to develop physician and practice site norms and other products. NCQA bears no responsibility for any use by third parties of any information or data released as provided in this Agreement, or for any effect of such release on Practice. 5. Practice understands that NCQA s survey of Practice under the PCMH 2014 Program does not constitute a warranty or representation of any kind by NCQA to any third parties, including, but not limited to employers, consumers or Practice s patients regarding the quality or nature of Practice s services. Practice further understands and agrees that a survey under the PCMH 2014 Program is not a replacement for Practice s evaluation, assessment and monitoring of its own services and procedures. Practice agrees not to misrepresent any information or report developed in conjunction with NCQA s survey under the PCMH 2014 Program. In communications with patients, third party payers, managed care organizations, and others, Practice may state that it has met PCMH 2014 Program standards and that it has achieved recognition under the PCMH 2014 Program. Practice may not characterize itself as an NCQA approved or NCQA endorsed practice. The use of these mischaracterizations or other similarly inappropriate statements may result in suspension or revocation of Practice s recognition under the PCMH 2014 Program. 6. Practice understands and agrees that any notes, internal memoranda, drafts or documents obtained or generated as part of the PCMH 2014 Survey and/or that reflect the internal thought processes and deliberations of NCQA, its officers, directors, employees, agents, contractors, auditors, surveyors, members of the PCMH 2014 Review Oversight Committee and members of the PCMH 2014 Reconsideration Committee shall hereby be deemed, considered and treated as peer review materials generated for the purpose of reviewing the professional services of Practice, notwithstanding any statutes or case law or other authority that would not recognize such materials and information as peer review materials. Under no circumstances will such materials or information be disclosed to Practice except as summarized in PCMH 2014 Final Results. With respect to any disclosure sought by third parties, such information and materials will be afforded any and all protections recognized as attaching to peer review materials under District of Columbia law; should such disclosure be ordered by a court, such court shall decide the extent to which Practice should also be entitled to disclosure of such information. 7. Practice agrees to defend, indemnify and hold harmless NCQA, its directors, officers, employees, agents, and representatives from and against any and all claims, liability, loss, damages, judgments, or injury, and all costs and expenses (including reasonable attorney fees and costs associated with any suits, actions, proceedings, claims, or official investigations or inquiries) of any kind related to (1) third party claims for malpractice or injury by Practice; (2) the Practice's failure to achieve desired results under the PCMH 2014 Program; or (3) payment and network decisions made by third parties based on Practice s recognition under the PCMH 2014 Program, unless and until any such claims, liability, loss, damages, judgments, injury, costs, expenses and attorney fees are found by a court of competent jurisdiction to have resulted from intentional acts or gross recklessness on the part of NCQA. NCQA s liability under this Section 7 is limited to actual damages. NCQA is not liable for consequential, special, incidental, indirect, exemplary, or punitive damages under this Agreement. NCQA PCMH (FINAL ver ) 2

3 8. Practice agrees that it will fully cooperate in any investigation by NCQA of a member, patient, provider, or health plan complaint submitted to NCQA. If the matter involves personal health information and/or relates to quality of care, NCQA shall provide Practice with an authorization to release information to NCQA signed by the member or patient or personal representative. Practice shall investigate any complaint referred to it by NCQA and shall respond in writing to NCQA and the person who submitted the complaint with Practice s resolution of each issue addressed in the complaint within thirty (30) calendar days of receipt of the complaint from NCQA. Failure to comply may materially impact Practice s recognition status. 9. The parties acknowledge that they have also entered into a Business Associate Agreement which among other things governs any use and disclosure of Protected Health Information as that term is defined under the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ), the Health Information Technology for Economic and Clinical Health Act provisions of the American Recovery and Reinvestment Act of 2009, Pub. Law No ( HITECH ), and the Federal privacy and security regulations established at 45 C.F.R. Parts 160 and 164, as amended from time to time. 10. Any and all claims or actions arising under this Agreement shall be governed by the law of the District of Columbia regardless of any applicable conflicts of laws principles, and shall be exclusively resolved by a court of competent jurisdiction within the District of Columbia. The parties acknowledge that it is their intent to enter into this Agreement by means of electronic signature. The person entering into this Agreement on behalf of Practice represents that by electronically signing this Agreement and by typing in and submitting their electronic signature to NCQA, they hereby bind Practice to the terms of this Agreement and further, that such individual signing on behalf of Practice is authorized to validly enter into and bind Practice to the terms of this Agreement. Applicant or Representative of Applicant(s) (For Applicant/Representative of Applicant(s) signature) Name of Organization: Gaston Family Health Services By: Title: Date: _ Lunie Osias Medical Home HIT Project Manager 12/12/ :42:48 AM National Committee for Quality Assurance By: Title: Date: _ Tom Fluegel Chief Operating Officer 12/12/ :42:48 AM NCQA PCMH (FINAL ver ) 3

4 NCQA PATIENT-CENTERED MEDICAL HOME (PCMH 2014) RECOGNITION PROGRAM PRICING Standard Survey Pricing The Standard Survey price is the fee for clinician practices undergoing the process for the first time and at the time of renewal. Pricing is by individual practice site. in the Practice Initial Fee for Practice to Obtain a Survey Tool License Application Fees for NCQA Review and Recognition 1 $80 $550 $630 2 $80 $1100 $1,180 3 $80 $1,650 $1,730 4 $80 $2,200 $2,280 5 $80 $2,750 $2,830 6 $80 $3,300 $3,380 7 $80 $3,850 $3,930 8 $80 $4,400 $4,480 9 $80 $4,950 $5, $80 $5,500 $5, $80 $6,050 $6, $80 $6,600 $6,680 Total License and Application Fees >50 $80 $6,600 + $10/ # >50 $6,680 + $10/ # >50 Discount for Sponsored Practices NCQA offers a 20 percent discount from the Full Survey to applicants sponsored by health plans, employers and other programs. PCMH applicants receive the discount when the: Practice has 15 or fewer physicians and Sponsor has ten or more applications in a market area within a twelve-month period. 4

5 in Practice Initial Fee for Practice to Obtain a Survey Tool License Application Fees for NCQA Review and Recognition Total License and Application Fees 1 $80 $440 $520 2 $80 $880 $960 in Practice Initial Fee for Practice to Obtain a Survey Tool License Application Fees for NCQA Review and Recognition Total License and Application Fees 3 $80 $1,320 $1,400 4 $80 $1,760 $1,840 5 $80 $2,200 $2,280 6 $80 $2,640 $2,720 7 $80 $3,080 $3,160 8 $80 $3,520 $3,600 9 $80 $3,960 $4, $80 $4,400 $4, $80 $4,840 $4, $80 $5,280 $5, $80 $5,280 $5,360 Add-On and Upgrade Survey Pricing To advance to a higher PCMH Recognition level (i.e., from Level 1 to Level 2 or Level 3, or from Level 2 to Level 3), the practice applies for an add-on survey. This does not require the purchase of an additional Survey Tool; NCQA provides the Practice with a Survey Tool based on their previous submission. The application fee for NCQA review and Recognition of an add-on survey is discounted at the 50 percent level of the standard application fees, even if practice paid the discounted fee for their initial survey. If eligible to upgrade from 2008 PPC-PCMH to PCMH 2014 a PCMH 2014 survey tool must be purchased and the application fee for NCQA review and Recognition of an upgrade survey is discounted at the 50 percent level of the standard application fees for each site. in Practice Add-On and Upgrade Survey Application Fee Pricing 1 $275 2 $550 3 $825 4 $1,100 5 $1,375 6 $1,650 7 $1,925 8 $2,200 9 $2, $2, $3, $3,300 5

6 Multi-Site Group Survey Pricing Note: The practice may use only one PPC-PCMH pricing discount for a survey. If the practice uses a sponsored discount, it may not also use the Multi-Site Group Survey discount. Several practice sites that share a common system or processes may be eligible for the NCQA Multi-Site Group Survey process. The organization must meet eligibility requirements and complete a self-assessment. If NCQA determines that a group of practices is eligible for a Multi-Site Group Survey, then the practice group purchases a Survey Tool for each practice site, plus an additional Survey Tool for the Multi-Site Group Survey. NCQA reviews the PCMH elements approved for the shared processes or systems first (the Multi- Site Group Survey), then applies the Multi-Site Group Survey results to all practice sites in the multi-site group. The remaining elements are completed for each practice site. To receive a multi-site group discount on initial surveys, the individual practice sites must submit Survey Tools for the PCMH evaluation process within twelve months of submitting the multi-site group Survey Tool. There is a discount of 50 percent on the Standard Survey fee for the individual practice sites applying under a Multi-Site Group Survey. That is, the full cost for an organization to apply through the Multi-Site Group Survey process = Multi-Site Group Survey application fee (from the first table below) and the application fees for each practice site (with a 50 percent discount on the Standard Survey fee as shown in the second table below) + Survey Tool purchases for each site and the Multi-Site Group Survey. Number of Practice Sites Within a Practice Group Multi-Site Group Survey Application Fee 1-2 NA 3 5 $1, $2, $3, $4, $5,500 >25 $6,600 at a Practice Site 1 $275 2 $550 3 $825 Practice Site Application Fee 4 $1,100 5 $1,375 6 $1,650 7 $1,925 8 $2,200 9 $2, $2, $3, $3,300 6

7 Reconsideration A practice may seek Reconsideration of a recognition status decision, as described in the Policies and Procedures. A fee of $550 per site or the add-on survey fee, whichever is less, will be charged, payable when the practice requests Reconsideration. Account ID: 9581, generated by NCQA Online PCMH Application Portal. 7