WorkfileContents.doc ASSIGNMENT # 2 Contract Review Analyze the sample physician contract provided below. Important negotiation language is missing from the contract. Using the Managed Care Checklist and your readings so far, analyze the contract and add the missing language to the appropriate sections of the contract. This assignment is worth 25% of your grade. Download the contract and add language to the appropriate sections in either RED or BOLD font. THIS AGREEMENT IS SUBJECT TO BINDING ARBITRATION PURSUANT TO THE FLORIDA GENERAL ARBITRATION ACT AND THE COMMERCIAL ARBITRATION RULES OF THE AMERICAN ARBITRATION ASSOCIATION MEDICAL GROUP SERVICES AGREEMENT This Medical Group Services Agreement (\"Agreement\") is made and entered into by and between , a Florida professional association, which employs or contracts with certain primary care and specialist physicians (\"Medical Group\"), and ABC Payor Health Plans of Florida, Inc. (\"ABC Payor\"), a Florida corporation licensed to operate as a health maintenance organization, as of this day of (the \"Effective Date\"). R E C I TA L S A. Medical Group is a medical group or professional association that provides or arranges for the provision of medical care services and health care services. B. ABC Payor is a corporation, which has the legal authority to enter into this Agreement, and to perform the obligations of ABC Payor hereunder with respect to the Benefit Programs identified on the attached Addenda to this Agreement. C. ABC Payor desires to enter into this Agreement to arrange for Medical Group to provide or arrange for the provision of Covered Medical Services to Members of various Benefit Programs. D. Medical Group desires to enter into this Agreement to provide or arrange for the provision of Covered Medical Services to Members of various Benefit Programs. E. ABC Payor desires to offer various Benefit Programs to Members in the Medical Group Service Area. The Effective Date of this Agreement with respect to a particular Benefit Program shall be the date of receipt by ABC Payor of all licensure, certifications and approvals or execution of contract(s) between ABC Payor and the appropriate Government Agencies as required for ABC Payor to offer or provide services in connection with, such Benefit Program in the Medical Group Service Areaas hereinafter provided. AGREEMENT NOW, THEREFORE, in consideration of the above recitals and the covenants contained herein, the parties hereby agree as follows: I. DEFINITIONS 1 WorkfileContents.doc ASSIGNMENT # 2 Contract Review Analyze the sample physician contract provided below. Important negotiation language is missing from the contract. Using the Managed Care Checklist and your readings so far, analyze the contract and add the missing language to the appropriate sections of the contract. This assignment is worth 25% of your grade. Download the contract and add language to the appropriate sections in either RED or BOLD font. 1. For purposes of this Agreement, the following terms shall have the meanings ascribed thereto unless another meaning is clearly required by the context in which such term is used. For purposes of Benefit Program(s) under the Medicare Advantage Program, definitions respecting the matters set forth below shall not differ from the definitions set forth in Title XVIII, Part C of the Social Security Act ( 1851 -1859; 42 U.S.C.A. 1395w-21 to -28 (West Supp. 1998)) and the rules and regulations promulgated thereunder. 2. Affiliate. Any person (as defined in Tex. Ins. CodeAnn. Art. 21.49-1, 2(k)) that directly, or indirectly through one or more intermediaries, is controlled by, or is under common control with ABC Payor. 3. Benefit Program. ABC Payor's, an Affiliate's or a Payor's performance of its obligations to provide, arrange or administer health care, provider networks, administrative or other related services pursuant to a written agreement between a public or private employer, Government Agency or other entity and ABC Payor on behalf of itself and an Affiliate. The Benefit Programs covered under this Agreement are listed hereto and on Addenda as applicable, which may be amended from time to time. 4. Benefit Program Requirements. The rules, procedures, policies, protocols and other conditions to be followed by Medical Group, Medical Group Providers and Participating Providers and Members with respect to providing Covered Medical Services under a particular Benefit Program. 5. Capitation Compensation. The per Member per month (PMPM) payment, indicated in the applicable Addenda to this Agreement, payable monthly for each Member who has selected or been assigned to an Medical Group Provider requiring Medical Group to provide or arrange for the provision of Medical Group Risk Services. 6. Contracted Services. The professional medical and other Covered Medical Services, except Non-Covered Services, to be rendered by Medical Group or a Medical Group Provider to a Member in accordance with this Agreement. Where and when applicable, Contracted Services are defined as Medical Group Risk Services and are specified in an exhibit to the applicable Addendum. 7. Coordination of Benefits. The allocation of financial responsibility between two or more payors of health care services, each with a legal duty to pay for or provide Covered Medical Services to a Member at the same time. 8. Copayment. That portion of the cost of Covered Medical Services that a Member is obligated to pay under a particular Benefit Program, including a deductible and co-insurance. A Copayment may be either a fixed dollar amount or a percentage of the applicable Participating Provider contract rate. ABC Payor will advise Participating Providers of the amounts or methods by which Copayments may be determined. and/or as outlined in the Provider Manual. Covered Medical Services (Covered Services). The Medically Necessary health care services and supplies that a Member is entitled to receive benefits for in accordance with a Benefit Program as outlined in the applicable Addendum to this Agreement. ABC Payor may waive any provision of the Benefit Program for an 9. 2 WorkfileContents.doc ASSIGNMENT # 2 Contract Review Analyze the sample physician contract provided below. Important negotiation language is missing from the contract. Using the Managed Care Checklist and your readings so far, analyze the contract and add the missing language to the appropriate sections of the contract. This assignment is worth 25% of your grade. Download the contract and add language to the appropriate sections in either RED or BOLD font. individual Member on a case-by-case basis; furthermore, ABC Payor shall have final authority in determining whether services are Covered Medical Services. 10. Delegated Services. The administrative services, including but not limited to, services provided under the Utilization Management Program, the credentialing of Medical Group Providers, and claims processing and payment to Medical Group Providers performed by Medical Group or Medical Group's designee. Medical Group shall perform Delegated Services on behalf of ABC Payor as required to provide or arrange for the provision of Covered Medical Services in accordance with this Agreement, as amended from time to time in accordance with Section 6.1 below, a delegation services agreement (the "Delegated Services Agreement"), as amended from time to time, and the HMO Laws. 11. Emergency (Emergency Services). Health care services provided in a hospital emergency facility or comparable facility to evaluate and stabilize medical conditions manifesting themselves by acute symptoms of a recent onset and sufficient severity, including but not limited to severe pain, that would lead a prudent layperson, possessing an average knowledge of medicine and health to believe that his or her condition, sickness, or injury is of such a nature that failure to get immediate medical care could result in: (a) placing the patient's health in serious jeopardy; (b) serious impairment to bodily functions; or (c) in the case of a pregnant woman, serious jeopardy to the health of the fetus. 12. Government Agency. Any local, State or federal government agency or entity with regulatory or other authority over ABC Payor, this Agreement or any Benefit Program. 13. CMS. The Health Care Financing Administration, an administrative agency of the United States government responsible for administering the Medicare Advantage Program. 14. CMS Contract. The contract between ABC Payor or Payor and CMS under the Medicare Advantage Program 15. HMO Laws means, collectively, the Health Maintenance Organization Act of 1973 (42 U.S.C.A. 300eto 300e-17) and applicable regulations thereunder, the Employee Retirement Income Security Act of 1974 (29 U.S.C.A. 1001-1461) and applicable regulations thereunder, the Florida Health Maintenance Organization Act (Tex. Ins. CodeAnn. Art. 20A.01-20A.38) and applicable regulations thereunder; Title XVIII and Title XIX of the Social Security Act and applicable regulations thereunder;all statutes, regulations and written guidance issued by the applicable Government Agency applicable to a Benefit Program; and any additional State, local or federal laws and regulations applicable to ABC Payor, as amended from time to time. 16. Medical Group Contracted Providers means, collectively, the physicians and allied health professionals who are under contract with Medical Group, but are not employees of Medical Group. 17. Medical Group Employed Physicians means, collectively, the physicians employed by Medical Group. 3 WorkfileContents.doc ASSIGNMENT # 2 Contract Review Analyze the sample physician contract provided below. Important negotiation language is missing from the contract. Using the Managed Care Checklist and your readings so far, analyze the contract and add the missing language to the appropriate sections of the contract. This assignment is worth 25% of your grade. Download the contract and add language to the appropriate sections in either RED or BOLD font. 18. Medical Group Provider. The physicians and allied health professionals who are employed by or contracted with Medical Group, or who are employed by Medical Group Providers, to provide Contracted Services to Members, including Medical Group Contracted Providers and Medical Group Employed Physicians. 19. Medical Group Risk Services. Contracted Services and such other Covered Medical Services as referenced in Exhibit 6 to Addendum B for which Medical Group has accepted Capitation Compensation under the applicable Benefit Programs to which the Addendum applies. 20. Medical Group Service Area. The geographic area(s) specified by county, or a portion thereof, in which Medical Group shall provide Contracted Services or arrange for the provision of Covered Medical Services for Members by Benefit Program which are described in the applicable Addendum to this Agreement. The Medical Group Service Area may be amended as agreed upon between ABC Payor and Medical Group in accordance with Section 6.1 below. 21. Medically Necessary. The term "Medically Necessary," as applied to a health care service, means that the service satisfies all of the following conditions: (a) it is required for the diagnosis, treatment or prevention of an illness or injury, or a medical condition such as pregnancy, (b) it is generally accepted as safe and effective treatment under standard medical practice in the community where the service is rendered and; (c) it is provided in the most cost-efficient manner that is consistent with an appropriate level of care. 22. Medicare Advantage Program. The comprehensive managed care program for Medicare created under the Balanced Budget Act of 1997 and contained in Title XVIII, Part C of the Social Security Act ( 1851-1859; 42 U.S.C.A 1395w-21 to -28 (West Supp. 1998)) and the rules and regulations promulgated thereunder. 23. Medicare Advantage Service Area. The portion of the Service Area approved by the appropriate Government Agency as being the area in which ABC Payor may market and enroll Medicare Advantage Members (as defined in Addendum C). At any given time during the term of this Agreement, the Medicare Advantage Service Area consists of the list of counties currently approved by the appropriate Government Agency as the Medicare Advantage Service Area. 24. Member. A person who is eligible to receive Covered Medical Services under a Benefit Program included in this Agreement, including a newborn baby who is a dependent of Member during the first 31 days following the baby's birth and/or legal adoption. 25. Non-Covered Services. Those health care services and supplies which are determined not to be Medically Necessary, or which otherwise are not Covered Medical Services under the applicable Benefit Program. 4 WorkfileContents.doc ASSIGNMENT # 2 Contract Review Analyze the sample physician contract provided below. Important negotiation language is missing from the contract. Using the Managed Care Checklist and your readings so far, analyze the contract and add the missing language to the appropriate sections of the contract. This assignment is worth 25% of your grade. Download the contract and add language to the appropriate sections in either RED or BOLD font. 26. Out-of-Area Services. Those Urgently Needed Services (as defined in Addendum ____ related to the Medicare Advantage Program) and Emergency Services provided while a Member is outside the Service Area. 27. Participating Provider. A hospital, physician, physician organization, other health care practitioner or other organization which has a direct or indirect contractual relationship with ABC Payor, an Affiliate, a Payor or another Participating Provider to provide certain Covered Medical Services. 28. Payor. ABC Payor, or any other public or private entity, including Medical Group, which provides, administers, funds, insures or is responsible for paying Medical Group Providers or Participating Providers for Covered Medical Services rendered to Members under a Benefit Program covered under this Agreement. 29. Payor Agreement. An agreement, directly or indirectly, between ABC Payor or an Affiliate and a Payor, or between a Payor and a Participating Provider. 30. Primary Care Physician (PCP). The Medical Group Provider who is responsible pursuant to the applicable Benefit Program for coordinating and managing the delivery of Covered Medical Services to certain Members selected or assigned to such physician and for whom Medical Group receives Capitation Compensation. 31. Prior Authorization. The written or telephonic, with written follow-up approval by ABC Payor, an Affiliate, a Payor, or other authorized person or entity, prior to admitting a Member to a hospital, or to providing certain other Covered Medical Services to a Member, which approval is required under the Utilization Management Program of the applicable Benefit Program. 32. Quality Assurance and Management Program. The functions, including, but not limited to, credentialing and certification of Medical Group Providers, review and audit of medical and other records, outcome rate reviews, peer review and provider appeals and grievance procedures ("Member Grievance Procedures" or "Medicare Advantage Grievance Procedures") performed or required by ABC Payor, an Affiliate, a Payor, or any other authorized person or entity, to review the quality of Covered Medical Services rendered to Members. 33. Referral. When required under a Benefit Program, the written approval from the Member's PCP which may specify the number of visits, the type and number of treatments, or period of time in relation to the diagnosis, that will constitute Covered Medical Services as may required under a Utilization Management Program and Benefit Program for a Member to receive Covered Medical Services from a physician (usually a specialist) or other health care professional or organization. Referral to a non-Participating Provider generally requires Prior Authorization. 34. Service Area. The geographical area in which ABC Payor is authorized by law to serve Members. As pertains to the terms and conditions of this Agreement, should the geographic area of the Service Area 5 WorkfileContents.doc ASSIGNMENT # 2 Contract Review Analyze the sample physician contract provided below. Important negotiation language is missing from the contract. Using the Managed Care Checklist and your readings so far, analyze the contract and add the missing language to the appropriate sections of the contract. This assignment is worth 25% of your grade. Download the contract and add language to the appropriate sections in either RED or BOLD font. increase at any time after the initial term of this Agreement, ABC Payor shall notify Medical Group in writing, using its best efforts to do so within thirty (30) days following such change. 35. State. The state of Florida, which has issued the licensure, certification and accreditation of ABC Payor and in which Medical Group and Medical Group Providers are to provide Contracted Services under this Agreement. 36. Urgent Care. (\"Urgent Care Services\"). Health care services, other than Emergency Services, which are typically provided in setting such as a physician or provider's office or urgent care center, as a result of an acute injury or illness that is sever or painful enough to lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that his or her condition, illness or injury is of such a nature that failure to obtain treatment within a reasonable period of time would result in serious deterioration of the condition or his or her health. 37. Utilization Management Program. The functions, including, but not limited to Prior Authorization, Referral and prospective, concurrent and retrospective review, performed or required by ABC Payor, an Affiliate, a Payor, or any other authorized person or entity, as required by the HMO Laws, to review and determine whether medical services or supplies which have been or will be provided to Members are covered under a Benefit Program and meet the criteria as Medically Necessary. II. PERFORMANCE PROVISIONS/REPRESENTATIONS OF MEDICAL GROUP AND MEDICAL GROUP PROVIDERS 2.1 Medical Group Representations and Warranties. (a) Medical Group warrants that it has the authority to contract on behalf of Medical Group Providers and to bind them to all of the terms and provisions of this Agreement. Medical Group will provide ABC Payor with representative agreements or certified excerpts thereof demonstrating such authority. Medical Group will notify Medical Group Providers of their rights and duties under this Agreement, and of all amendments and modifications thereto. (b) Medical Group agrees to provide ABC Payor with copies of its current standard agreements with Medical Group Providers concurrently with the execution of this Agreement. Medical Group also agrees to provide its written policies and procedures pursuant to such agreements, its bylaws and articles of incorporation and any modifications thereto. Medical Group shall inform ABC Payor of any modifications to its standard agreements with Medical Group Providers, its written policies and procedures pursuant to such agreements and its bylaws and articles of incorporation (hereinafter referred to as \"Medical Group Amendments\") and shall provide ABC Payor with written documentation of such Medical Group Amendments (1) within thirty (30) days of implementation concerning written policies and procedures pursuant to such agreements and its bylaws and articles of incorporation and (2) at least thirty (30) days in advance of implementation concerning standard agreements with Medical Group Providers. 6 WorkfileContents.doc ASSIGNMENT # 2 Contract Review Analyze the sample physician contract provided below. Important negotiation language is missing from the contract. Using the Managed Care Checklist and your readings so far, analyze the contract and add the missing language to the appropriate sections of the contract. This assignment is worth 25% of your grade. Download the contract and add language to the appropriate sections in either RED or BOLD font. (c) Medical Group represents that the terms of this Agreement do not conflict with the terms of its employment of Medical Group Employed Physicians or the terms of its agreements with Medical Group Contracted Providers; nonetheless, Medical Group represents that the terms of this Agreement shall apply in any situation where there is an inconsistency or conflict with the terms of any agreement between the Medical Group Provider and Medical Group or with respect to any matter which is not addressed in any such agreement between the Medical Group Provider and Medical Group, and that Medical Group shall be responsible to ABC Payor for any such inconsistency or conflict in terms. This provision shall supersede any similar provision in any agreement between Medical Group and a Medical Group Provider. (d) Medical Group shall provide ABC Payor with, but not limited to, a list of the names, practice locations, federal tax identification numbers, medical practice license numbers, DEA number, DPS number, Medicare certification number, professional practice name and legal partnerships, and the business hours (the \"Provider Information\") of all Medical Group Providers in a format acceptable to Medical Group and ABC Payor. The format in which Medical Group shall submit Provider Information shall be included as Addendum D to this Agreement. ABC Payor shall notify Medical Group of all such physicians and allied health professionals approved by ABC Payor to be Medical Group Providers. Medical Group shall provide ABC Payor with updated additions, deletions, status changes, and address changes to the list of Medical Group Providers in a format acceptable to ABC Payor. ABC Payor and Medical Group shall mutually agree when to include additional physicians and other providers of health care as Medical Group Providers under this Agreement. (e) Medical Group shall ensure that all Medical Group Providers comply with all applicable terms and conditions of this Agreement, including, without limitation, the obligations of Medical Group set forth in Sections 2.2 through 2.23, 3.1 through 3.11 and 5.1 through 5.4 hereof, and to ensure that the obligations contained in such Sections are included in Medical Group's agreements with Medical Group Providers. (f) Medical Group shall notify ABC Payor in writing at least sixty (60) days prior to any action by Medical Group to terminate a Medical Group Provider's agreement or employment with Medical Group. When sixty (60) days prior notice is not possible, Medical Group shall provide as much advance notice as possible. Medical Group shall immediately notify ABC Payor whenever a Medical Group Provider fails to renew his or her agreement or employment with Medical Group, whenever Medical Group has reason to believe a Medical Group Provider will fail to renew his or her agreement or employment with Medical Group, and whenever Medical Group knows of an occurrence causing the immediate termination of a Medical Group Provider under Section 2.1(h) of this Agreement. (g) Medical Group shall terminate the participation of a particular Medical Group Provider under this Agreement immediately upon request of ABC Payor, in the event of: 7 WorkfileContents.doc ASSIGNMENT # 2 Contract Review Analyze the sample physician contract provided below. Important negotiation language is missing from the contract. Using the Managed Care Checklist and your readings so far, analyze the contract and add the missing language to the appropriate sections of the contract. This assignment is worth 25% of your grade. Download the contract and add language to the appropriate sections in either RED or BOLD font. (1) (2) any action by an Medical Group Provider which, in the reasonable judgment of ABC Payor, constitutes gross misconduct or may jeopardize the health and safety of a Member; (3) (h) any misrepresentation or fraud by an Medical Group Provider in the credentialing process; an Medical Group Provider's loss, suspension or restriction of his or her license to practice medicine or dentistry, narcotic registration certificate issued by the Drug Enforcement Administration (\"DEA\"), certification to participate in Medicare or Medicaid. Medical Group shall terminate the participation of a particular Medical Group Provider under this Agreement upon request of ABC Payor, in the event of: (1) (2) a Medical Group Provider's failure to maintain professional liability insurance in accordance with this Agreement; or, (3) (i) a Medical Group Provider's failure to comply with ABC Payor's or a Payor's Utilization Management Program, Quality Assurance and Management Program and/or ABC Payor's credentialing criteria; or the involuntary loss of medical staff privileges Process of Termination. At least ninety (90) days prior to the termination of a Medical Group Provider's status as a Participating Provider, ABC Payor shall provide written explanation to Medical Group of the reasons for termination, except in the case of imminent harm to patient health, action against license to practice medicine or dentistry or fraud or malfeasance, in which case termination may be immediate. On request and before the effective date of the termination of a Medical Group's Provider's status as a Participating Provider, but within a period not to exceed sixty (60) days, an Medical Group Provider shall be entitled to a review of ABC Payor's proposed termination by an advisory review panel, except in a case in which there is imminent harm to patient health or an action by a state medical or dental board, or other medical or dental licensing board, or other licensing board or Government Agency, that effectively impairs the Medical Group Provider's ability to practice medicine, dentistry , or another profession, or in a case of fraud or malfeasance. The advisory review panel shall be composed of Participating Providers including at least one representative in the Medical Group Provider's specialty or a similar specialty, if available, appointed to serve on the standing quality assurance committee or utilization review committee of ABC Payor. The decision of the advisory review panel must be considered but is not binding. ABC Payor shall provide to the affected Medical Group Provider, on request, a copy of the recommendation of the advisory review panel and ABC Payor's determination. Medical Group Provider shall be entitled to an expedited review process 8 WorkfileContents.doc ASSIGNMENT # 2 Contract Review Analyze the sample physician contract provided below. Important negotiation language is missing from the contract. Using the Managed Care Checklist and your readings so far, analyze the contract and add the missing language to the appropriate sections of the contract. This assignment is worth 25% of your grade. Download the contract and add language to the appropriate sections in either RED or BOLD font. by ABC Payor on request of Medical Group Provider. Except for termination based on imminent harm to Members, ABC Payor shall notify Members of the termination by ABC Payor of Medical Group Provider's status as a Participating Provider at least thirty (30) days prior to the effective date of the termination or the advisory review panel makes a formal recommendation. (j ) (1) Effect of Termination. In the event that a Member is receiving Contracted Services at the time the Medical Group Provider's contract or employment terminates, an Medical Group Provider shall continue to provide Contracted Services to the Member until: (a) treatment is completed; or (b) the Member is assigned to another Participating Provider; or (c) Member ceases to be covered. Compensation to Medical Group for such Contracted Services shall be at the rates contained in the Addendum that applies to the applicable Benefit Program. With respect to Benefit Programs under the Medicare Advantage Program, Medical Group acknowledges and agrees that in the event of ABC Payor's or an applicable Payor's insolvency or other cessation of operations, benefits to Members will continue through the period for which payment from CMS to ABC Payor or such Payor has been paid, and benefits of Members who are inpatients in a hospital on the date of insolvency or other cessation of operations will continue until their discharge. Compensation to the Medical Group Provider shall be in accordance with the contract between Medical Group and the Medical Group Provider, not to exceed ninety (90) days from effective date of termination or beyond nine (9) months in the case of a Member who at the time of termination has been diagnosed with a terminal illness or a Member who at the time of termination is past the 24th week of pregnancy, extends through delivery of the child, immediate postpartum and the follow-up checkup within the first six weeks of delivery. (2) Member Notification. Medical Group and Medical Group Providers remain liable for any obligations or liabilities arising from conduct prior to the effective termination date. ABC Payor shall notify Members seeking professional services after the date of termination that the Medical Group Provider is no longer a Participating Provider. If an Medical Group Provider is terminated for reasons other than the Medical Group Provider's request, Members will not be notified until the effective date of the termination or until such time as the review panel makes a formal recommendation. If an Medical Group Provider is terminated for reasons related to imminent harm, ABC Payor will notify Members immediately. 9 WorkfileContents.doc ASSIGNMENT # 2 Contract Review Analyze the sample physician contract provided below. Important negotiation language is missing from the contract. Using the Managed Care Checklist and your readings so far, analyze the contract and add the missing language to the appropriate sections of the contract. This assignment is worth 25% of your grade. Download the contract and add language to the appropriate sections in either RED or BOLD font. (3) 2.2 Medical Group shall secure and compensate its own Medical Director who shall oversee Medical Group's compliance with ABC Payor's professional review programs, and assist ABC Payor in the development of medical policy guidelines. Such Medical Director shall interface with ABC Payor's Medical Director to support ABC Payor's Utilization and Quality Assurance and Management Programs. Individual Provider Representations and Warranties. Medical Group represents and warrants, for itself or for each Medical Group Provider, as applicable, that Medical Group or Medical Group Provider: (a) (b) provides Contracted Services in compliance with all applicable local, State, and federal laws, rules, regulations and professional standards of care; (c) is certified to participate in Medicare under Title XVIII of the Social Security Act, and in Medicaid under Title XIX of the Social Security Act or other applicable State law pertaining to Title XIX of the Social Security Act; (d) holds active staff privileges on the medical staff(s) of one or more hospital Participating Providers, where applicable; (e) holds a current DEA narcotic registration certificate, where applicable, and current State narcotics license; (f) shall maintain such licensure, compliance, certification and registration throughout the term of this Agreement; (g) shall maintain all required professional credentials and meet all continuing education requirements necessary to retain Board certification or eligibility in Medical Group Provider's area(s) of practice or to meet the ABC Payor minimum requirements of professional credentials in the absence of such Board certification or eligibility; and (h) 2.3 is licensed by the State(s) to provide Contracted Services; shall maintain a professional relationship with each Member for whom Medical Group renders Contracted Services, and shall be solely responsible to such Member for treatment and medical care. Provision of Services. Medical Group agrees to render, or to ensure that Medical Group Providers render, Contracted Services to Members of the Benefit Programs covered under this Agreement, in accordance with: (a) The terms and conditions of this Agreement; (b) All laws, rules and regulations, policies and procedures applicable to Medical Group, ABC Payor, Affiliates and Payors; 10 WorkfileContents.doc ASSIGNMENT # 2 Contract Review Analyze the sample physician contract provided below. Important negotiation language is missing from the contract. Using the Managed Care Checklist and your readings so far, analyze the contract and add the missing language to the appropriate sections of the contract. This assignment is worth 25% of your grade. Download the contract and add language to the appropriate sections in either RED or BOLD font. (c) The Utilization Management Program, Quality Assurance and Management Program, Benefit Program Requirements and grievance, appeals and other policies and procedures of the particular Benefit Program under which the Covered Medical Services are rendered; (d) The same manner, and with the same availability, as services are rendered to other patients; (e) The minimum clinical quality of care and performance standards that are professionally recognized and adopted, accepted or established by ABC Payor. (f) Where and when applicable, Medical Group shall accept compensation for each Benefit Program outlined in the attached Addenda from an Affiliate in return for services to Members of Benefit Programs offered by an Affiliate. 2.4 Offices and Hours. Medical Group shall cause Medical Group Providers to maintain such offices, equipment, patient service personnel and allied health personnel as may be necessary to provide Contracted Services under this Agreement. Medical Group shall cause Medical Group Provider to provide Contracted Services under this Agreement at Medical Group Provider's offices during normal business hours, and to be available to Members by telephone twenty-four (24) hours a day, seven (7) days a week for consultation on medical concerns. Further, Medical Group Provider shall be available to provide Covered Medical Services on an Emergency basis twenty-four (24) hours a day, seven (7) days a week. Medical Group shall be available to authorize or deny authorization for Contracted Services for post stabilization care following treatment or stabilization of an Emergency medical condition, within the time appropriate to the circumstances relating to the delivery of the service and the condition of the patient, but in no case to exceed one hour. 2.5 Coverage. Medical Group Provider shall arrange for coverage, in the event of Medical Group Provider's illness, vacation or other absence from his or her practice, and shall use his or her best efforts to ensure that such coverage is by a Participating Provider. If such coverage is not by a Participating Provider, Medical Group and Medical Group Provider shall use his or her best efforts to cause such covering professional to abide by the terms of this Agreement. Non-Discrimination and Acceptance of Members. Medical Group and Medical Group Provider shall not discriminate against any Member in the provision of Contracted Services hereunder, whether on the basis of the Member's age, sex, race, color, religion, ancestry, national origin, disability, health status, source of payment, utilization of medical or mental health services or supplies or other unlawful basis in accordance with the HMO Laws, and additional State, local, and federal laws and regulations. Furthermore Medical Group and Medical Group Provider shall not discriminate against any Member in the provision of Contracted Services because of the filing by such Member of any complaint, grievance or legal action against Medical Group, a Medical Group Provider, ABC Payor, an Affiliate, or a Payor. Medical Group shall assure that if an Medical Group Provider is accepting new patients from health maintenance organizations other than ABC Payor, such Medical Group Provider shall continue to accept new Members. If an Medical Group Provider will no longer be accepting new patients from any health 2.6 11 WorkfileContents.doc ASSIGNMENT # 2 Contract Review Analyze the sample physician contract provided below. Important negotiation language is missing from the contract. Using the Managed Care Checklist and your readings so far, analyze the contract and add the missing language to the appropriate sections of the contract. This assignment is worth 25% of your grade. Download the contract and add language to the appropriate sections in either RED or BOLD font. maintenance organizations, Medical Group will notify ABC Payor in writing, at least sixty (60) days prior to the patient panel closure. 2.7 Subcontracting. Medical Group shall not subcontract for the performance of Contracted Services under this Agreement without the prior written consent of ABC Payor. Medical Group may subcontract for the provision of such services with entities acceptable to ABC Payor. A subcontract with a Medical Group Provider shall be consistent with the terms and conditions of this Agreement and include an express agreement by Medical Group Provider (i) to perform the obligations of Medical Group and Medical Group Provider under this Agreement, (ii) that following payment by ABC Payor to Medical Group in accordance with the terms and conditions of this Agreement, Medical Group is solely responsible, and ABC Payor has no responsibility or liability, for any amounts owed to a Medical Group Provider for Contracted Services provided to Members by such Medical Group Provider; and (iii) ABC Payor has no responsibility or liability as a result of nonpayment or other breach by Medical Group under its subcontract with Medical Group Provider. Medical Group agrees to oversee Medical Group Provider's performance of its obligations under such subcontract and to be accountable to ABC Payor and Members for the negligent performance or nonperformance of any obligation under such subcontract related to the provision of health care services to Members. MEDICAL GROUP AGREES TO INDEMNIFY AND HOLD ABC PAYOR, A FFILIATES, AND PAYORS HARMLESS FOR ANY LOSS, COST, CLAIM, OR LIABILITY WHICH MAY ARISE AS A RESULT OF ANY BREACH OR NEGLIGENT PERFORMANCE OR NONPERFORMANCE BY MEDICAL GROUP PROVIDER OF ITS OBLIGATIONS UNDER THE SUBCONTRACT BETWEEN MEDICAL GROUP AND MEDICAL GROUP PROVIDER RELATED TO THE PROVISION OF HEALTH CARE SERVICES TO MEMBERS, OR MEDICAL GROUP'S NONPAYMENT OR OTHER BREACH BY MEDICAL GROUP UNDER ITS SUBCONTRACT WITH MEDICAL GROUP PROVIDER. Each Medical Group Provider must meet ABC Payor's credentialing requirements as a condition precedent to Medical Group Provider's status as a Participating Provider under this Agreement. Medical Group shall furnish ABC Payor with copies of the first page and signature page of such subcontracts within ten (10) days of execution of this Agreement and ten (10) days of execution of any subsequent subcontracts by Medical Group. Each such subcontractor shall meet ABC Payor's credentialing requirements, prior to the subcontract becoming effective. 2.8 Utilization Management Requirements. Medical Group agrees and shall cause all Medical Group Providers to participate in, cooperate with and comply with all decisions rendered in connection with ABC Payor's, an Affiliate's, or a Payor's Utilization Management Program. Medical Group also agrees and shall cause all Medical Group Providers to provide such records and other information as may be required or requested under such Utilization Management Program, provided that Medical Group has the appropriate and valid written authorization to do so from the Member in accordance with applicable law regarding the confidential treatment of medical information. Medical Group shall accept delegation of and perform utilization management with respect to Contracted Services provided under this Agreement in accordance with a separate Delegated Services Agreement between ABC Payor and Medical Group. Medical Group shall perform such utilization management in accordance with the performance standards 12 WorkfileContents.doc ASSIGNMENT # 2 Contract Review Analyze the sample physician contract provided below. Important negotiation language is missing from the contract. Using the Managed Care Checklist and your readings so far, analyze the contract and add the missing language to the appropriate sections of the contract. This assignment is worth 25% of your grade. Download the contract and add language to the appropriate sections in either RED or BOLD font. and criteria of ABC Payor or a Payor. ABC Payor shall have the right to audit Medical Group's performance of utilization management, for compliance with the Delegation Services Agreement for utilization management services, as solely determined by ABC Payor and to reassume the obligation for utilization management in the event ABC Payor determines that Medical Group either does not have the capacity to perform, or is not effectively performing utilization management in accordance with such Delegation Services Agreement. 2.9 Prior Authorization and Referrals. Medical Group shall be available for post Emergency stabilization authorizations as required by Section 2.4, above. Unless a particular Benefit Program or Utilization Management Program contains no such requirement, or except in an Emergency, Medical Group agrees not to seek payment from ABC Payor or a Payor for Contracted Services rendered to a Member unless Prior Authorization or a Referral was obtained for the rendering of such services. Such Prior Authorization or Referral may be issued by ABC Payor or the applicable Payor. Other than in an Emergency, Medical Group agrees to attempt to obtain Prior Authorization or a Referral, by telephone if necessary, before providing Contracted Services or ordering other Covered Medical Services. If Prior Authorization or a Referral cannot be obtained, Medical Group agrees to notify ABC Payor or the applicable Payor and the appropriate Participating Provider, as applicable, as soon as possible, but no later than twenty-four (24) hours after providing the Contracted Services, or ordering the other Covered Medical Services, or on the next working day. 2.10 Participating Providers/Mental Health Care Providers. Except in an Emergency, as otherwise described in the applicable Benefit Program Requirements, or as otherwise required by law, Medical Group shall refer Members only to Participating Providers for Covered Medical Services. For certain specialized procedures and services which cannot be rendered by the Participating Providers, ABC Payor or a Payor shall discuss the use of appropriate non-participating providers with Medical Group. Additionally, if so required under the applicable Benefit Program Requirements, Medical Group shall admit Members only to designated hospital Participating Providers. If Medically Necessary Covered Medical Services are not available through ABC Payor's Participating Provider network, ABC Payor will, upon request of a Participating Provider, within a reasonable time period, allow referral to a nonParticipating Provider. In the event that a requested referral is denied, the request shall be reviewed by a specialist of the same or similar specialty or the type of physician or provider to whom a referral was requested if requested by the Member or the Member's Primary Care Physician. Medical Group and Medical Group Providers shall direct any Member who appears to be in need of mental health or chemical dependency services to the provider designated by ABC Payor to provide or arrange for such mental health and chemical dependency services. A Referral is not required. ABC Payor will provide reasonable notice to Medical Group and Medical Group Providers in the event ABC Payor alter its arrangements for such mental health and chemical dependency services. Case Management. ABC Payor shall arrange for case management services to Members with complex medical onditions to ensure that care is provided in a manner which encourages quality, continuity of care and cost-effectiveness. Medical Group and Medical Group Provider shall cooperate fully with ABC 2.11 13 WorkfileContents.doc ASSIGNMENT # 2 Contract Review Analyze the sample physician contract provided below. Important negotiation language is missing from the contract. Using the Managed Care Checklist and your readings so far, analyze the contract and add the missing language to the appropriate sections of the contract. This assignment is worth 25% of your grade. Download the contract and add language to the appropriate sections in either RED or BOLD font. Payor in such case management activities, including, without limitation, providing information that may be required for ABC Payor to determine the need for case management and to transfer of Members to designated Participating Providers for cost effective care. 2.12 Out-of-Area Services. Medical Group and Medical Group Provider shall cooperate fully with ABC Payor in ABC Payor's activities relating to management and coordination of Out-of-Area Services, including, without limitation: (a) providing information necessary to transfer a Member to a Participating Provider in the Medical Group Service Area; (b) immediately notifying ABC Payor of known or suspected provision of Out-of-Area Services to a Member; (c) and accepting the transfer of a Member to the care of Medical Group or Medical Group Provider following such Member's receipt of Out-of-Area Services. 2.13 Quality Assurance and Management Program. Medical Group shall be solely responsible for the quality of Contracted Services rendered to Members. The quality of Contracted Services rendered to Members shall be monitored under the Quality Assurance and Management Program applicable to the particular Benefit Program. Medical Group agrees to participate in, cooperate with and comply with all decisions rendered by ABC Payor or a Payor in connection with a Quality Assurance and Management Program. Medical Group also agrees to provide such medical records, utilization management records and credentialing records with reasonable notice upon receipt of written request, and such review data and other information as may be required or requested under a Quality Assurance and Management Program in accordance with all applicable laws governing the confidentiality of medical records. Medical Group agrees to provide outcome reporting in accordance with, but not limited to, the then current version of the Health Plan Employer Data and Information Set (HEDIS). In the event that the standard or quality of care furnished by Medical Group or Medical Group Provider is found to be unacceptable under any Quality Assurance and Management Program, ABC Payor shall give written notice to Medical Group to correct the specified deficiencies within the time period specified in the notice. Medical Group shall correct such deficiencies within that time period. 2.14 Credentialing of Medical Group and/or Medical Group Providers. Medical Group shall accept delegation of and perform credentialing of Medical Group Providers. Medical Group shall perform such credentialing in accordance with the performance standards and criteria of ABC Payor or a Payor as outlined in a separate Delegated Services Agreement between ABC Payor and Medical Group. ABC Payor shall have the right to audit Medical Group's performance of its credentialing functions from time to time, and to reassume the obligation for credentialing in the event ABC Payor determines that Medical Group either does not have the capacity to perform, or is not effectively performing, credentialing of Medical Group Providers. 2.15 Notice of Adverse Action. Medical Group shall notify ABC Payor in writing, within three (3) days of receiving any written or oral notice of any adverse action, including, without limitation, any malpractice suit or arbitration action, or other suit or arbitration action naming or otherwise involving Medical 14 WorkfileContents.doc ASSIGNMENT # 2 Contract Review Analyze the sample physician contract provided below. Important negotiation language is missing from the contract. Using the Managed Care Checklist and your readings so far, analyze the contract and add the missing language to the appropriate sections of the contract. This assignment is worth 25% of your grade. Download the contract and add language to the appropriate sections in either RED or BOLD font. Group, a Medical Group Provider, ABC Payor or any Payor, and of any other event, occurrence or situation which a reasonable person would infer might materially interfere with, adversely affect, modify or alter performance of any of Medical Group's or Medical Group Provider's duties or obligations under this Agreement, consistent with all applicable peer review, attorney-client, and attorney work product protections of Medical Group, Medical Group Contracted Providers, ABC Payor and any insurance carrier of either party. Medical Group shall forward to ABC Payor any written complaint or grievance or oral complaint or grievance, relating to quality of care, of a Member against Medical Group, a Medical Group Provider, ABC Payor or any Payor in a log containing all Member complaints and setting forth the date and nature of each complaint and whether the complaint was made orally or in writing. Medical Group Contracted Providers must also report all Member complaints to Medical Group. Medical Group shall maintain a written record of any Member complaint and provide such record to ABC Payor promptly upon request. Medical Group also shall notify ABC Payor promptly of any action against Medical Group or Medical Group Provider with respect to any license, certification under Title XVIII or Title XIX or other applicable section of the Social Security Act or other State, federal or local law. 2.13 2.16 Professional Liability Insurance/Medical Group Risk Services Reinsurance. Medical Group, at its sole cost and expense, shall maintain insurance coverage as follows: (i) comprehensive general liability insurance with limits of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) as an annual aggregate; and (ii) professional liability insurance with limits of at least two million dollars ($2,000,000) per occurrence and as an annual aggregate. Participating Providers are required to maintain a minimum professional liability insurance in the amount of two hundred thousand dollars ($200,000) per claim and six hundred thousand dollars ($600,000) in aggregate of all claims per policy year. At minimum, all Participating Providers shall maintain professional liability insurance in an amount equal to the greater of the highest amount required by law or the requirements within this paragraph. Medical Group agrees to provide ABC Payor with written evidence, acceptable to ABC Payor, of such insurance coverage within three (3) days of such request by ABC Payor. Medical Group also agrees to notify, or to ensure that its insurance carriers notify ABC Payor at least thirty (30) days prior to any proposed termination, cancellation or material modification of any policy for all or any portion of the coverage provided for above. At its sole cost and expense, Medical Group shall maintain stop loss insurance covering all claims from Medical Group Providers and other providers for all Covered Medical Services which are Contracted Services rendered to Members in excess of fifteen thousand dollars ($15,000) per Member per calendar year as are incurred during the life of this Agreement. 15 WorkfileContents.doc ASSIGNMENT # 2 Contract Review Analyze the sample physician contract provided below. Important negotiation language is missing from the contract. Using the Managed Care Checklist and your readings so far, analyze the contract and add the missing language to the appropriate sections of the contract. This assignment is worth 25% of your grade. Download the contract and add language to the appropriate sections in either RED or BOLD font. 2.17 2.18 Listing of Medical Group Providers. Medical Group agrees on behalf of itself and Medical Group Providers that ABC Payor, any Affiliate and Payors may list the name, address, telephone number and other factual information of Medical Group and all of Medical Group Providers, in its marketing and informational materials. Medical Group shall supply all printed materials and other information relating to its operations, description of services, or information necessary for ABC Payor to complete a request for proposal within three (3) days of ABC Payor's request. Non-Solicitation. Neither Medical Group, nor any Medical Group Provider nor any employee, agent or subcontractor of Medical Group shall solicit or attempt to convince or otherwise persuade any Member not to participate or to discontinue participation in any ABC Payor or Payor Benefit Program for which Medical Group or Medical Group Provider renders Contracted Services under this Agreement. Further, Medical Group and Medical Group Providers and their employees and subcontractors, shall treat Members promptly, fairly and courteously. ABC Payor and Medical Group agree that nothing in this Agreement shall be construed as a limitation of Medical Group's or Medical Group Provider's right or obligation to discuss in good faith with the Member, prospective enrollee, or former Member (collectively the "Patient") information regarding the Patient's health, including the Patient's medical condition, treatment options, or information regarding the provisions, terms, requirements or services of ABC Payor as they relate to the medical needs of the Patient, all in accordance with HMO Laws. 2.19 Encounter Reporting. For Members for which Medical Group receives Capitation Compensation under this Agreement, Medical Group shall provide ABC Payor with the Member/Medical Group Provider encounter information, via personal computer diskette, magnetic tape or electronic transmission in the format specified in Exhibit 7 of Addendum A and/or Exhibit 4 Addendum C or its successor format, for each encounter with a Member during a calendar month. Such electronic encounter information materials shall be complete, accurate and provided to ABC Payor by the fifteenth (15th) day of the month following the month in which the encounter occurred. Additionally, Medical Group shall promptly provide ABC Payor with all corrections to and revisions of such encounter data. 2.20 Benefit Programs; New or Additional Benefit Programs. The Effective Date of this Agreement with respect to a particular Benefit Program(s) shall be the first day of the subsequent month following the later to occur of the following events: (a) the date on which this Agreement is executed by ABC Payor and Medical Group; or (b) the date of receipt by ABC Payor of all licensure, certification and regulatory approvals or execution of contract(s) between ABC Payor and a Government Agency as required for ABC Payor to offer, or provide services in connection with, such Benefit Program in the Medical Group Service Area. If ABC Payor is unable to obtain such licensure, certification or regulatory approvals, or contract with a Government Agency after due diligence, ABC Payor shall notify Medical Group and both parties shall be released from any liability under this Agreement with respect to the Benefit Program(s) in question; provided however, that if such licensure, certification or regulatory approval, or contract with a Government Agency, is conditioned upon amendment of this Agreement, then this Agreement shall be amended automatically pursuant to Section 6.1 hereof. Furthermore, Medical Group 16 WorkfileContents.doc ASSIGNMENT # 2 Contract Review Analyze the sample physician contract provided below. Important negotiation language is missing from the contract. Using the Managed Care Checklist and your readings so far, analyze the contract and add the missing language to the appropriate sections of the contract. This assignment is worth 25% of your grade. Download the contract and add language to the appropriate sections in either RED or BOLD font. acknowledges that ABC Payor may develop new or additional Benefit Programs in Medical Group's Service Area, and Medical Group agrees to negotiate with ABC Payor in good faith to amend this Agreement to include such new or additional Benefit Programs as requested by ABC Payor. Where a new Benefit Program falls under existing Addenda(s), then the applicable contract rates shall automatically apply. 2.21 Payment of Applicable Taxes. Medical Group shall be solely responsible for the collection and payment of any sales, use or other applicable taxes on the sale or delivery of medical services. 2.22 Timely Assignment of Members. Where required under a Benefit Program, ABC Payor shall require Members to select specified Participating Providers at the time of enrollment. In the event a Member does not select a PCP or other Participating Providers within sixty (60) days, ABC Payor shall automatically assign such Member (the \"Undesignated Member\") to the participating provider determined by ABC Payor to receive all Undesignated Members The Member shall be informed of the name, address, and telephone number of the assigned PCP or other Participating Providers. Upon automatic assignment of PCP, the Member may change to another PCP of choice. The first change shall not be counted as a change in providers for the purposes of limitation. ABC Payor shall notify the selected PCP within thirty (30) working days of Member assignment. 2.23 Member Grievance Procedures. Medical Group shall abide by the determination of the applicable Payor's Member Grievance Procedure, including but not limited to grievance procedures for resolving disputes regarding the necessity for continued treatment, as described in the ABC Payor Member Grievance Procedures. Medical Group shall cause each Medical Group Provider to post, in the office, a notice to Member(s) on the process for resolving complaints. The notice must include the Florida Department of Insurance's toll free telephone number. ABC Payor will not engage in any retaliatory action, including refusal to renew coverage or cancellation of coverage, against an employer or Member because the employer, Member or person acting on behalf of the employer or Member has filed a complaint against or appealed a decision of ABC Payor. ABC Payor will not engage in any retaliatory action, including termination or refusal to renew a contract, against a physician or provider, because the physician or provider has, on behalf of a Member, filed a complaint against or appealed a decision of ABC Payor. In the event the Member or Medicare Advantage Member submits an appeal to ABC Payor, ABC Payor shall provide Medical Group with the Member or Medicare Advantage Member appeal. Medical Group shall review the Member or Medicare Advantage Member appeal, performing any necessary research or investigation and providing a determination and response to ABC Payor within three (3) days of receipt from ABC Payor, for a Member appeal, or as required by the Florida Department of Insurance, and within twenty-four (24) hours of receipt from ABC Payor for a Medicare Advantage Member, or as required by the then current CMS guidelines. 2.24 Termination of Members. Medical Group may request to terminate Members as patients of Medical Group or Medical Group Contracted Providers, as applicable, only as specified in this Section 2.22. 17 WorkfileContents.doc ASSIGNMENT # 2 Contract Review Analyze the sample physician contract provided below. Important negotiation language is missing from the contract. Using the Managed Care Checklist and your readings so far, analyze the contract and add the missing language to the appropriate sections of the contract. This assignment is worth 25% of your grade. Download the contract and add language to the appropriate sections in either RED or BOLD font. ABC Payor shall attempt to resolve the problem without termination of the Member and be solely responsible for notifying a Member in the event ABC Payor agrees with Medical Group's request. ABC Payor will address Medical Group's request to terminate a Member within thirty (30) days after receipt of the request or within fifteen (15) days after receipt of any additional needed information. Medical Group and Medical Group Contracted Providers shall promptly provide ABC Payor with any information they have pertaining to the proposed termination. Medical Group and Medical Group Contracted Providers shall cooperate with any terminated Member and ABC Payor to arrange an orderly transfer of the Member's care to another Participating provider including without limitation providing all medical information necessary for the transfer of the Member's care, subject to and in accordance with state and federal laws and regulations regarding the confidentiality of medical records. ABC Payor's right to terminate a Member from an ABC Payor health plan pursuant to the applicable Membership Agreement are preserved and in no way altered by this Section 2.22. The specific circumstances under which Medical Group or a Medical Group Contracted Provider may terminate a Member as a patient are as follows: (i) Failure to Pay Copayments. Medical Group and Medical Group Contracted Provider may request ABC Payor terminate a Member for failure to pay Copayments by giving ABC Payor at least thirty (30) days written notice, during which time the Member may avoid termination by paying the amount due. (ii) Member Misconduct. Medical Group and Medical Group Contracted Providers may request ABC Payor terminate a Member who (a) harasses, threatens, or is unruly or abusive to a physician or any personnel of Medical Group or Medical Group Contracted Providers, (b) engages in conduct detrimental to the operation of Medical Group or Medical Group Contracted Provider's delivery of services to its other patients; or (c) refuses to follow any policy or procedure of Medical Group or Medical Group Contracted Provider, which policy or procedure is reasonable and conforms to current standards for policies and procedures for medical practices in the community; provided that such grounds may not be used to terminate a Member unless Medical Group or Medical Group Contracted Provider, as the case may be, would also use such grounds to terminate a patient who is not a Member. (iii) Failure to Achieve Satisfactory Physician-Patient Relationship. Because of the personal nature of the relationship between the Member and the Primary Care Physician, a satisfactory physician-patient relationship is important to delivery of effective health care services. In circumstances where the relationship is or becomes unsatisfactory. Medical Group shall permit the Member to select another Primary Care Physician. If the Member has had unsatisfactory relationships with at least three (3) Primary Care Physicians, after consultation between Medical Group and the Member, if Medical Group determines that a satisfactory physician- 18 WorkfileContents.doc ASSIGNMENT # 2 Contract Review Analyze the sample physician contract provided below. Important negotiation language is missing from the contract. Using the Managed Care Checklist and your readings so far, analyze the contract and add the missing language to the appropriate sections of the contract. This assignment is worth 25% of your grade. Download the contract and add language to the appropriate sections in either RED or BOLD font. patient relationship cannot be achieved between the Member and any Primary Care Physician, Medical Group and Medical Group Contracted Providers may request ABC Payor terminate such Member. (iv) Fraud, Abuse or Misuse of Identification Card. Medical Group and Medical Group Contracted Providers may request ABC Payor terminate a Member who commits fraud in the use of Covered Medical Services or permits the use of his or her ABC Payor identification card by any other person, or misuses the card himself or herself or otherwise defrauds Medical Group or any Medical Group Contracted Provider. (v) Member's ABC Payor Coverage Terminates. Medical Group and Medical Group Contracted Providers may request ABC Payor terminate a Member if ABC Payor has terminated the Member's Benefit Program. (vi) Refusal to Follow Medical Advice or Treatment. In the event a Member refuses to follow the advice of Medical Group or a Medical Group Contracted Provider, such refusal may hinder continuation of the physician-patient or provider-patient relationship and obstruct the provision of proper medical care. If in the opinion of Medical Group or Medical Group Contracted Provider, there is no professionally acceptable alternative treatment, Medical Group or Medical Group Contracted Provider shall so advise the Member. Only if the Member still refuses to accept the recommended treatment or procedure may Medical Group or Medical Group Contracted Provider request ABC Payor to terminate the Member. 2.25 Contract Authority. Medical Group hereby appoints ABC Payor as Medical Group's attorney -in-fact with authority to negotiate and enter into a