Medicare - Physician Responsibilities |
OVERVIEW OF PHYSICIAN RESPONSIBILITIES
As part of continuing quality improvement program and in accordance with Centers for Medicare & Medicaid Services (CMS) regulations and applicable National Committee for Quality Assurance (NCQA) guidelines, ConnectiCare will monitor provider performance against the standards outlined in this section and in accordance with the provider agreement.
ConnectiCare Requirements
Primary Care Physicians (PCPs):
- Act as a health care manager for members to arrange and coordinate their medical care, including but not limited to, routine care, and follow-up care after the receipt of emergency services.
- Offer accessibility for appointments a minimum of twenty (20) hours per week, excluding on-call hours. In addition, all physician offices must have twenty-four (24) hour, on-call capability seven days a week, either directly or through an answering service, not an answering machine.
- Offer timely accessibility for appointments to members for:
- Preventive care visits within 60 days
- Routine primary care visits within 30 days
- Urgent care visits with 24 hours
- After-hours coverage
Specialists:
• Provide continuity and coordination of care by sending a written report to PCPs regarding any treatment or consultation provided to beneficiaries, whenever the beneficiary receives services from a specialist provider, whether the service was a result of a PCP referral or the beneficiary made his/her own arrangements.
• All physician offices must have twenty-four (24) hour on-call capability, either directly or through an answering service, not an answering machine.
All Contracted Physicians:
• Review policy statements issued through the Physician & Provider Manual or its updates via the Office Visit, our provider newsletter, and adhere to the policies and administrative requirements of ConnectiCare.
• Refund overpayments made to you by ConnectiCare, as indicated in a written notice from ConnectiCare. Such refunds must be made to ConnectiCare within thirty (30) days of receipt of the written notice unless other arrangements are made in writing and accepted by ConnectiCare.
• Arrange for the provision of medical services to ConnectiCare members by a participating practitioner after hours, on weekends, vacations, and holidays. Services from non-participating covering practitioners may not be covered, unless otherwise approved by ConnectiCare.
• Help members obtain their benefit coverage by getting written pre-authorization for services that require it, and prior to referring for out-of-plan services, as appropriate.
• Facilitate candid discussion with members regarding appropriate or medically necessary treatment options for their condition, regardless of cost or benefit coverage. Such discussion should include complete current information concerning a diagnosis, treatment, and prognosis, in terms that the member (or designee) can be expected to understand.
• Provide to members the information necessary to give informed consent prior to the start of any procedure or treatment.
• Maintain appropriate liability insurance coverage, as stipulated in the applicable provider agreement(s).
• Maintain appropriate medical records regarding members and their treatment, recognizing that said records are confidential and ensuring that they are maintained in accordance with legal and ethical requirements concerning confidentiality and security.
• Cooperate with ConnectiCare or its designee in the resolution of members' complaints, expedited appeals, appeals and/or grievances.
• Comply with other administrative requirements as specified in the applicable contract or stipulated in this Physician & Provider Manual or its updates.
• Promote the efficient delivery of medical services to maximize health care resources and the member's premium dollar and improve quality of care provided.
• Refrain from providing treatment to the physician’s own family members.
• Provide medical information in a culturally-competent manner to all beneficiaries, including those with limited English proficiency or reading skills, diverse cultural and ethnic backgrounds, and physical or mental disabilities.
• Be aware that by seeing a member of our Private Fee-for-Service plan for non-emergency care you agree to the Terms & Conditions of Payment. (Terms & Conditions are available on our website at www.connecticare.com.)
• Abide by the rules of the Plan's pharmacy drug program, as set forth in this Manual.
NCQA Requirements
All Contracted Physicians:
• Comply with ConnectiCare medical records policy, quality assurance programs, medical management programs, and HEDIS data collection.
CMS Marketing Guidelines
All Contracted Physicians:
• Comply with CMS Marketing Guidelines for provider-based activities. The guidelines, available by
clicking here, govern how providers can and cannot inform or educate patients about enrollment and plan information.
