Common use of Provider Competition and Standardized Reimbursement Clause in Contracts

Provider Competition and Standardized Reimbursement. (a) Contractor shall measure and monitor the magnitude of provider competition that exists within regionally defined Contractor provider networks and where Contractor operates on behalf of the Exchange. Metrics to measure the magnitude of competition shall include an evaluation of primary care and specialty distribution within a region, the cost and quality of affiliated hospital and provider network(s) available for Plan Enrollees and the overall performance and results of existing value based reimbursement programs. (b) Contractor shall evaluate its current approaches to payment, the selection of providers within a region and the potential financial and quality impact of increased competition between network providers, provider organizations and hospital systems. Contractor shall consider the importance of encouraging competition when developing any new approaches to payment and network partnerships. On an annual basis, or at the request of the Exchange, Contractor agrees to provide the Exchange with specific strategies and approaches to increasing competition within their provider networks. (c) Contractor shall develop, pilot and implement successful strategies to improve reimbursement for primary care services, including strategies to reduce payment discrepancies between primary and specialty care within geographic regions. Contractor shall conduct an analysis of price variation among its network Providers, by procedure and service type, and share information with the Exchange. Included in the analysis will be those regions or other market segments with the widest variation and greatest opportunities for cost savings through a reference or value-pricing scheme. (d) If Contractor has more than one fee schedule in place with providers, by line of business or other delineation, all services provided to Plan Enrollees are to be reimbursed using the most competitive fee schedule in place at time of treatment. If existing provider agreements preclude Contractor from accessing rates or other fee arrangements, Contractor shall amend contracts to include Plan Enrollees.