AHLA. V. Complex Contracting in the 21st Century between Payers and Providers

Transcription

1 AHLA V. Complex Contracting in the 21st Century between Payers and Providers Lisa A. Hathaway Vice President and Chief Medicare Counsel Aetna Bethesda, MD Alan E. Schabes Benesch Friedlander Coplan & Aronoff LLP Cleveland, OH Annual Meeting June 26-28, 2017

2 American Health Lawyers Association 2017 Annual Meeting Lisa Hathaway, Esq. Alan E. Schabes, Esq. Agenda General Overview Types of Alternative Payment Models Fraud and Abuse Issues Bundling Waivers under Anti Kickback Statute and Stark Medicare Loss Ratio Issues Contracting Issues and Requirements 2 1

3 Generally The Centers for Medicare and Medicaid Innovation ( CMMI ) was established by 3021 of the Affordable Care Act ( ACA ). As set forth in 3021 of the Affordable Care Act, the purpose of the [CMMI] is to test innovative payment and service delivery models to reduce program expenditures... while preserving or enhancing the quality of care furnished to individuals under such titles. CMMI has identified many opportunities for its Alternative Payment Models, including: (a) promoting broad based reform in primary care via patient centered medical homes and other innovating care models; (b) supporting healthcare IT infrastructure; (c) varied payments for imaging based on best practices; and (d) giving States authority to test and evaluate payment reform. 3 Generally Models include: 1) Accountable Care Organizations ( ACO ); 2) Bundled Payments for Care (generally, BPCI ); 3) Comprehensive Care for Joint Replacement ( CJR ); 4) Other Models: Acute Myocardial Infarction ( AMI ); Coronary Artery Bypass Graft ( CABG ); and Surgical Hip and Femur Fracture Treatment ( SHFFT ). 4 2

4 (1) ACOs Generally The ACO and similar models are designed to incentivize health care providers to become accountable for a patient population by investing in infrastructure and processes that promote coordinated, quality, and efficient care. Hospitals, payors, and clinicians that participate in an ACO are financially accountable for the quality and cost of care for Medicare beneficiaries who are enrolled in traditional fee for service programs. To the extent participants are successful, they will share in the Medicare savings they promote. On the other hand, ACOs will be held financially responsible in the event costs exceed benchmark levels. There are several different ACO models. 5 ACO: Models Pioneer Model designed for organizations and providers that had experience in coordinated care across settings; this model concluded on December 31, 2016; A majority of the 8 participants sharing in savings as of the 2015 Performance Year End report. Under the Pioneer model, provider groups were able to move from a shared savings payment model to a population based payment model outside of the Medicare Shared Savings Program. Designed to work in coordination with private payors. 6 3

5 ACO: Models Next Generation Model Also designed for providers experienced in coordinating care for populations of patients. This model allowed participants to assume higher levels of financial risk than as compared to the Pioneer and Medicare Shared Savings Program models there are currently 44 participants 7 ACO: Models Investment Model In contrast to the Pioneer model, the Investment Model is designed for ACOs that are participating in the Medicare Shared Savings Program. Participants receive a combination of an upfront fixed payment; and upfront variable payment based on the number of assigned beneficiaries, and a monthly variable payment based on the ACOs size. There are currently almost 500,000 Medicare beneficiaries covered by this model as of January

6 (2) BPCI: Generally The Bundled Payments for Care Improvement ( BPCI ) initiative consists of four broadly defined models linking payments for beneficiaries receiving multiple different services during an episode of care. Under these initiatives, Medicare makes a single payment which is subsequently divided amongst the various caregivers. 9 BPCI: Models Model 1 Model 1 defined the episode of care as the inpatient stay in the acute care hospital; Medicare paid the hospital, retrospectively, a discounted amount based on the Inpatient Prospective Payment System and physicians under the Medicare Fee Schedule; Concluded December 31, 2016; 10 5

7 BPCI: Models Model 2 Medicare makes a retrospective bundled payment where actual expenses are reconciled against a target price for an episode of care. During the episode inpatient stay in the acute care hospital, post acute care, and related services ending either 30, 60, or 90 days after discharge providers receive FFS payments. Model 2 participants may select up to 48 clinical episodes. After reconciliation as against the target price, a payment or recoupment amount is made as compared to the established target price. Medicare payments for hospitalization and 90 days post discharge declined $864 more for orthopedic surgery episodes at BPCI participating hospitals than at non participating hospitals because of reduced use of institutional post acute care following hospitalization. Model 2 is ongoing and currently has 335 acute care hospitals and 204 physician group practice participants. 11 BPCI: Models Model 3 Medicare continues to make FFS payments to providers and subsequently reconciles charges against a set target. Here, the episode of care is triggered by the inpatient stay and begins at initiation of the post acute care services with a SNF, IRF, LTC, or HHA. As under Model 2, participants in Model 3 can select from 48 clinical conditions to test in this model. Naturally, SNFs and then HHAs were the most frequent participants in Model 3. Here, SNF payments and SNF days after a triggering episode of care declined relative to comparison groups in support of the Model s goal. 12 6

8 BPCI: Models Model 4 Medicare makes a single payment to a hospital that encompasses all services furnished by the hospital, physicians, and other caregivers for the defined episode of care. Again, participants may select up to 48 clinical conditions to test in this model. Physicians and other clinicians submit no pay claims to Medicare for tracking and evaluation purposes, but are otherwise paid out of the single lump sum payment made to the hospital. Under this model, it is important to note, that all readmissions for 30 days after discharge are included in the payment amount. There are currently 5 participating hospitals in this model. 13 (3) Comprehensive Joint Replacement (CJR) The Comprehensive Care for Joint Replacement ( CJR ) model s goal: to support better and more efficient care for patients undergoing hip and knee replacement. Under CJR, the episode of care begins with the admission of a patient to a participating hospital who is ultimately discharged under DRG 469 or 470, major joint replacement or reattachment of lower extremity, with or without major complications or comorbidities, respectively. Similar to BPCI Models 2 and 3, participants are paid under traditional Medicare FFS. Medicare sets a target price based on historical spending, adjusted based on risk stratification. At the end of each participant year, the total payments to each participant hospital will be compared to the target price. Depending on quality and spending performance, the hospital will either receive an additional payment ( gainshare ), or be required to repay Medicare ( alignment ) for a portion of the episode spending. 14 7

9 CJR (cont.) Federal rules set forth the terms under which a CJR participant hospital may distribute either a gainsharing payment or receive an alignment payment from the other actors involved in delivering care (each a CJR Collaborator ). Hospitals may not make or receive payments except in accordance with a sharing arrangement with CJR Collaborators as formalized and documented in a signed collaborator agreement. CMS may review any sharing arrangement for compliance. Hospitals are required to include update their own compliance programs to include oversight over their CJR collaborators at the board or governing body level. 15 CJR (cont.) The specific terms of the collaborator agreement are highly regulated: The arrangement must comply with all applicable fraud and abuse laws. Additionally, a CJR Collaborator s participation must be voluntary and without penalty; No party may condition the opportunity to make or receive gainsharing payments or alignment payments conditional on the volume or value of referrals between the hospital and CJR Collaborator; No hospital can make a gainsharing payment to a CJR Collaborator that is subject to any action for non compliance with fraud and abuse laws, underscoring the importance of effective compliance programs. In addition to fraud and abuse considerations, arrangements must not incentivize a reduction in providing medically necessary services; Payments to a CJR Collaborator must be at least in part based on achieving certain quality benchmarks. 16 8

10 CJR (cont.) In addition to setting forth the goals of the sharing arrangement, CMS sets forth the specific components that are required to be in each agreement with CJR Collaborators. The agreement must contain a description of the relationship, including the parties, date, purpose, financial terms, safeguards, etc.; The agreement must require the CJR Collaborator to act in compliance with CJR regulations; The agreement must require the collaborator to have a valid TIN or NPI during the term; The CJR Collaborator must have a compliance program; The must be a specific methodology for determining the cost savings to Medicare; The agreement must state the quality criteria used to determine the gainsharing payment. The hospital must have the right to recoup payments in the event an overpayment is assessed. 17 CJR Contracting Requirements The Collaborator Agreement must comply with the following: Describe the sharing arrangement between the hospital and the CJR collaborator, specifically: The parties; date; purpose and scope; financial or economic terms, including frequency of payment, method of accounting, and amounts; safeguards to ensure alignment payments made solely for purposes related to sharing responsibility for funds needed to repay Medicare; plans for redesign; care coordination; success measures; management and staff information. 18 9

11 CJR Contracting Requirements Cont d. The Agreement must contain a requirement that the Collaborator and its employees/contractors must comply with CJR Rules: Medicare enrollment requirements; Compliance program; Internal cost saving verification mechanisms; Criteria for gainsharing; Ability to recoup overpayments. 19 (4) Other Models On December 20, 2016, CMS published a final rule regarding several Episode Payment Models: AMI; CABG; SHFFT; and changes to CJR (collectively EPM Models ). Unlike the previously discussed ACO and BPCI Models, participation in the EPM Models is mandatory, putting hospitals at financial risk. Delays: Mandatory bundled payments under the EPM Models were set to begin July 1, However, by Interim Rule, published March 21, 2017, CMS delayed the start for until October 1, 2017, and sought comments with respect to further delaying the implementation of the AMI as discussed in this Section (and certain changes to the CJR program) until January 1, 2018, in order to align payment periods with the calendar year. The delay does not impact existing BPCI and CJR models only changes to the CJR model. By Final Rule, published May 20, 2017, CMS confirmed its intent to delay implementing changes to the CJR, and implementing the mandatory AMI, CABG, and SHFFT models until January 1,

12 Other Models Acute Myocardial Infarction On January 1, 2018, acute care hospitals in 98 selected geographic areas will participate in retrospective bundled payments for items and services that are related to Acute Myocardial Infarction Model ( AMI ) treatment and recovery beginning with hospitalization and continuing for 90 days after discharge. This model holds the hospital financially accountable for the quality and cost of an episode of care. An AMI episode begins on the admission of an eligible Medicare fee forservice beneficiary that results in a discharge paid under DRGs and Other Models Coronary Artery Bypass Graft Model CMS will begin making mandatory bundled payments under the Coronary Artery Bypass Graft Model ( CABG ). Under this model CMS will begin making bundled payments to acute care hospitals in 98 selected geographic areas for CABG treatment as defined by DRGs , to also include recovery and care for 90 days following discharge

13 Other Models Surgical Hip and Femur Fracture Treatment CMS will begin making mandatory bundled payments to acute care hospitals for Surgical Hip and Femur Fracture Treatment ( SHFFT ) as defined by DRGs Unlike AMI and CABG, this program is limited to 67 discreet geographic areas. 23 Fraud and Abuse Implications Federal Anti Kickback Statute ( AKS ) Physician Self Referral Law ( Stark Law ) Beneficiary Inducement of Civil Monetary Penalties ( CMP ) Gainsharing Civil Monetary Penalty Law 24 12

14 Gainsharing Civil Monetary Penalty Law Purpose: To address the risk of a physician holding back on necessary care or discharging patients early in the interest of reducing costs and services in gainsharing arrangements. Prohibits A hospital or critical access hospital knowingly makes a payment, directly or indirectly, to a physician as an inducement to reduce or limit services with respect to individuals who: (1) are entitled to benefits under part A or part B Medicare or to medical assistance under a State plan; and (2) are under the direct care of the physician, the hospital or critical access hospital shall be subject to a CMP of not more than $2,000 for each such individual with respect to whom the payment is made. 25 Gainsharing Civil Monetary Penalty Law (cont.) Any physician who accepts receipt of a payment described above is also subject to the CMP for each individual with respect to whom the payment is made. Physicians who certify that patients meet the requirements of 42 USC 1395(f)(a)(2)(C) or 1395n(a)(2)(A) knowing that the requirements are not met is subject to a CMP of the greater of $5,000 or three times the amount of payments for services made pursuant to such certification

15 AKS and Stark Law Bundling Waivers The Secretary may waive certain fraud and abuse requirements as necessary to carry out the provisions of the Medicare Shared Savings Program. On October 29, 2015, the OIG and CMS jointly published a Final Rule with regard to final waivers in connection with the Shared Saving Program. This Final Rule sets forth 5 waivers that provide flexibility for ACOs to pursue a wide array of activities, including those in the Shared Savings Program. 27 AKS and Stark Law Bundling Waivers (cont.) ACO Pre Participation Waiver. The OIG waives the Stark Law and AKS for ACO related start up arrangements in anticipation of participating in the Shared Savings Program. ACO Participation Waiver. Under this waiver the OIG waives the Stark Law and AKS application during the term of the ACO s participating agreement under the Shared Savings Program and for a certain duration after the participating agreement ends. Shared Savings Distributions Waiver. Again, the Stark and AKS are waived with respect to distributions and uses of payments earned through the Shared Savings Program. ACO Waiver. The OIG will not enforce the AKS for ACO arrangements that implicate the Stark Law. Patient Incentive Waiver. OIG will waive beneficiary inducement provisions of the CMP and the AKS for medically related incentives offered by ACOs, ACO participants, or ACO providers and suppliers under the Shared Savings Program for encouraging preventative care and compliance with treatment regimens

16 BPCI Model 1 Waiver On September 13, 2012, the OIG and CMS jointly issued waivers for specified arrangements involving BPCI Model 1 Participants. Protects hospitals and physicians from Stark Law and AKS exposure from sharing gains, or Incentive Payments, made under Model 1. The waiver does not protect distribution of funds from any other source or funds generated by means other than the approved gainsharing methodology outlined in the Gainsharing Arrangement, or financial arrangements other than Incentive Payments. The waiver does not protect payments made to reduce or limit medically necessary services. 29 BPCI Model 1 (cont.) Protects Incentive Payments received by an enrolled practitioner, including those made directly or indirectly to the enrolled practitioner by a BPCI Awardee, and incentive payments received by a BPCI entity and passed through to an enrolled practitioner. Incentive Payments received and retained by a BPCI entity for the BPCI entity s administrative services directly related to administration of the gainsharing arrangement are protected. The waiver applies to incentive payments derived from internal hospital cost savings generated by the BPCI Awardee s approved gainsharing arrangement during the performance years

17 BPCI Models, 2, 3, and 4 On July 26, 2013, the OIG and CMS jointly issued waivers for specific programs involving BPCI Models 2, 3, and 4. Models 2 and 3 include payments for both inpatient stays in an acute care hospital and post acute care and related services, the waivers protect a post acute provider s arrangement with a Model Awardee Hospital. Waivers under these models protect those covered from Stark Law, AKS, and CMP exposure. Waivers include the Savings Pool Contribution Waiver for internal cost savings contributed by Episode Integrated Providers ( EIPs ) to the BPCI Savings Pool. Such cost savings contributed to the Savings Pool must be realized by the EIP and result from care redesign undertaken by the EIP with providing services and items to beneficiaries within specific episodes of care. The contribution must consist only of internal cost savings. The EIP (contributor) must not knowingly make the contribution to induce the reduction of medically necessary items or services to patients. 31 BPCI Models, 2, 3, and 4 (cont.) Under the Incentive Payments Waiver, certain distributions from the BPCI Savings Pool made pursuant to the BPCI Agreement are afforded protection. Incentive Payment means: (a) a payment made directly or indirectly from the BPCI Savings Pool to an Awardee or EIP Pursuant to a Gainsharing Arrangement set forth in a Participant Agreement, (b) a payment of a portion of a BPCI Savings from an EIP to a Gainsharer, pursuant to a written gainsharing agreement, or (c) a payment made directly or indirect from the BPCI Savings Pool to a BPCI entity for administrative services pursuant to a gainsharing arrangement. BPCI entities in receipt of Incentive Payments must pass the entire amount through to an EIP or other BPCI entity, less amounts appropriately retained for administrative services. Again, the party making the Incentive Payment must not knowingly induce the recipient to reduce or limit Medically Necessary Services

18 BPCI Models, 2, 3, and 4 (cont.) As set forth in the Patient Engagement Incentive Waiver, participants are afforded protection with respect to items or services provided by a Model Awardee, EIP, or Gainsharer to a Model Beneficiary for free or below market value. The below market items or services must have a reasonable connection to the medical care provided. Specifically, the items and services must be in kind and be preventative care items that advance one of the following clinical goals: (1) adherence to a drug regime; (2) adherence to a follow up care plan; or (3) management of a chronic disease or condition. 33 BPCI Models, 2, 3, and 4 (cont.) In Model 4, AKS enforcement is waived under the Professional Services Fee waiver. Compensation paid by an Episode initiator/hospital to a physician or nonphysician that has not opted out that may otherwise implicate the AKS for Part B covered services furnished to a Model 4 Beneficiary during an Episode of Care is protected. Requirements include the compensation arrangement be fully compliant with a Stark Law exception set forth at 42 CFR (c), (d), or (l): employment; personal services; or fair market value, respectively. Additionally, payments must not knowingly be made to limit medically necessary items or services

19 Waivers for CJR On November 16, 2015, the OIG and CMS jointly issued waivers for specified arrangements involving CJR Model participants. The OIG will waive enforcement of the AKS and Stark Law in connection with gainsharing payments (surplus) and alignment payments (deficit) arrangements. Such payments must satisfy the requirements set forth in 42 CFR and 42 CFR Medical Loss Ratio Commercial plans (small, individual, large group) must achieve ratio of 80 or 85% MA Plans 85% Directs percentage of payments for members services and quality care activities Decrease amounts spent on administration profits Affects plan arrangements with vendors and providers Commercial remit payment to employers or policy holders MA Remit payment to CMS Penalties for MA ban on new enrollment (3 years not meeting) or lose CMS contract (5 years not meeting) Other risks false claims, CMPs, reputation Data retention 11 years, 10 years after year filed 36 18

20 Basic Calculation Numerator Incurred claims plus any expenses to improve health care quality (and other limited adjustments (additional items for Medicare Advantage such as amount reduction in Part B premium) Denominator Earned premiums less federal and state taxes and licensing or regulatory fees Incurred claim what the plan pays to providers for covered services i.e. what is in the EOC or in the benefits agreement (insurance policy) Exclusions from incurred claims non claims costs such as network development, claims processing, administration fees, medical record copying costs, etc. (see later for more) Medical Claim Paid + Quality Improvement Expense + Fraud & Abuse (+ Supplemental Benefits for MA) (ex. 85) Customer Premium Taxes & Assessments Paid Licenses & Fees Paid (ex. 100) = 85% * this is for MA MLR 37 Definition of Quality Improvement Expense 45 CFR or 42 CFR (a) and (a) Activity must meet the ALL FOUR of the following requirements: i) improve health quality; ii) increase likelihood of desired outcome in ways that can be objectively measured and provide verifiable results; iii) be directed at individual enrollees or segments of enrollees or provide health improvements to population as long as no costs are incurred by enrollees; and iv) be grounded in evidence based medicine, widely accepted clinical practice, criteria used by professionals such as medical associations, accreditation bodies gov t agencies or other nationally recognized bodies

21 In addition, the QIE activities must be Primarily designed to: (Meet one or more of 4 Items in Bold) Activity must be primarily designed to produce likelihood of desired outcome. Examples: effective case mgmt., care coordination, chronic disease mgmt., care compliance initiatives such as PCMH, ID ethnic racial or cultural disparities for best clinical practice, non electronic quality reporting and documentation, accreditation fees directly related to quality of care activities Implement and promote wellness Ex. assessments, life style coaching to specific and measureable improvements, coaching program for chronic disease, actual awards, incentives, bonuses, HIT to support such activities Prevent hospital readmits through comprehensive discharge programarrangement and manage transitions Ex. Patient centered education and counseling, personalized post discharge reinforcement, HIT to support such QI activities Improve patient safety, reduce medical errors, lower infection and mortality rates Ex. best clinical practice to reduce harm, activities using evidenced based medicine ( EBM ), prospective UR to id adverse drug interactions 39 Exclusions from QIE Primarily designed to control or contain costs Activities paid for with grant money Retrospective and concurrent UR review Certain prospective UM Benefits administrative type activities Fraud prevention (can claim recoveries) Credentialing Marketing expenses Cost of provider contracting, executing contracting Prospective UR that does not meet the definition of QIE Claims adjudication Handling enrollee and provider appeals Record copying costs 40 20

22 More Complex Analysis FFS payments Capitation to a provider is generally all medical costs. Is payment going to a licensed hc provider or to a vendor? Vendors likely a portion of capitation payment is for administration (If a provider is generally all incurred claim, but if to non clinical entity, may not be.) Payments for medical cost reduction Is likely administrative Bonus payment based on cost saving measures (most likely not QIE) Ex. Payment to hospital to reduce length of stay or to reduce total claims costs vs. bonus payment to decrease admissions to less than 1200 a month. Bonus or shared savings payments impt to understand whom Dr. Group?, Hospital system?, ACO?, 3 rd party entity? Payment for achieving quality metrics or care coordination Bundled payments are they for covered services and to whom are the payments being made? 41 Clinical Risk Bearing Entity Must meet 4 Part Test 1) Entity contracts with an issuer to deliver, provide, or arrange for delivery & provision of clinical services to issuer s enrollees (and entity is not issuer) 2) Entity contractually bears financial & utilization risk for delivery, provision, or arrangement but entity is not issuer with respect to those services 3) Entity delivers, provides or arranges for the delivery and provision of clinical services through a system of integrated care delivery that provides for the coordinating of care, and sharing of clinical information, and which includes programs such as provider performance reviews, tracking clinical outcomes, communicating evidence based guidelines to entity s clinical providers, and others; and 42 21

23 Clinical Risk Bearing Entity 4) Functions other than clinical services that are included in the payment (capitation or fee for service) must be reasonably be related or incident to the clinical services, and must be performed on behalf of the entity or the entity s providers. Must meet ALL 4 Prongs Ex. Vendor meets No. 1 insurer s enrollees and No. 2 at risk for financial & utilization (not just financial), but not No. 3 & 4. Ex. Apply to third parties such as IPAs, PHOs, ACOs PBM will not meet this, generally. 43 Network Adequacy ACA Plan standards sufficient no. & type of providers, includes essential providers, includes mental health & substance abuse State standards on network adequacy vary and some are detailed NCQA availability practitioners, accessibility of services NAIC model network adequacy standards 44 22

24 CMS Network Adequacy Standards Must meet when an entity applies to be a MA or Part D plan or upon expansion 90% of MA enrollees residing in a county must have access to certain provider types Depends on county designation of large metro, metro, micro, rural, and certain extreme counties CMS has details in their HPMS system regarding the providers and facilities Does not include HH, DME or transplant providers It is a time and distance standard Ex. oncology, neurology, cardiology, psychiatry, rheumatology, urology, PCPs Limited and rare exceptions for not meeting the standards retirement, moving, provider or facility will not contract with any MAOs, exclusive contract with one MAO or prove a unique pattern of care Applicability to contracting Plans will reach out to contract Can effect ability to expand to a new county if a provider or facility refuses to contract Relationships Effects on members 45 Provider Directory Requirements ACA Plans on the Exchange ACA requirements for QHPs Machine readable No longer accepting patients List provider name, license, credentials, specialty, contact info, accommodations for limited English Update every 30 days for Exchange NAIC, States, & Medicaid NAIC in 2015 AMA has tried to propose standards State of CA SB 137 FL, GA, IL, MD, WA Pending laws NJ, NY, CT, RI Medicaid Plans have directory requirements 46 23

25 CMS Plan Directory Requirements Under CMS scrutiny and evaluation since 2016 AHIP study validated the difficulty of maintaining the directory and getting the information Need for accurate information for members CMS has issued several sets of memo guidance No misleading info, indicate if providers are only available to certain enrollees. Ex. Native American Indians, only available for home visits or practice concierge medicine Clearly note non physicians Required to maintain online and provide hard copy directory upon request Elements are listed in Chapter 4 MA Manual Quarterly outreach to providers to verify accuracy is required (was monthly) Plan contract requirements notice of any change within 30 days, or even penalties for not providing Educate providers on need for updated and accurate info. Reaching out by , phone call, fax, letter to verify accuracy 47 Contracting Considerations Credentialing Not excluded, suspended, disbarred & monthly checks of OIG & SAMs data bases Payment terms clear, prompt pay, interest Definitions still impt! Clear obligations of both parties for services What is a covered service? Medical necessity and coverage will vary by product What products does the contract cover?? Non Discrimination health status, mental, type of coverage, race, color Provide scope of services within provider s licensure and as they treat other non Plan patients 1557 requirements ex. translators, interpreters 48 24

26 Mandated Medicare and Medicaid Provisions Expectation CMS requires certain language when a MA Plan contracts with a first tier, downstream and related party Template flowdown provisions Use of other terms that are Plan legal requirements in addition Medicaid requirements ex. hold harmless, encounter data, detail the services, credentialing and provider ID info, cultural competency, confidentiality and maintenance of records, report Impt. Example Language Comply with all applicable CMS requirements Hold harmless language Keep records for 10+ years Right privacy and confidentiality Right HHS, CMS, Comptroller Gen & Plan to inspect, auditor, requires records, electronic info and computers Clearly set forth delegated duties (separate attachment or contract) 49 Terminations Important for network adequacy MA Plan & providers must give at least 60 days notice for non cause terminations Key relationships 180 to 1 year notice Plans will want a with cause loss of licensure or accreditation, significant fines, penalties, or member issues, or regulatory issues, and non compliance with laws, lack of insurance, insolvency/bankruptcy Providers will want a with cause for late payment that is not cured, Plan regulatory issues Right to cure or not? Short time frame, plan discretion to extend Transition obligations need to be part of termination 50 25