The MA organization must establish a formal mechanism to consult with the physicians who have agreed to provide services under the MA plan offered by the organization, regarding the organization’s medical policy, quality improvement programs and medical management procedures, and ensure that the following standards are met:
- Practice guidelines and utilization management guidelines:
- Are based on reasonable medical evidence or a consensus of health care professionals in the particular field
- Consider the needs of the enrolled population
- Are developed in consultation with contracting physicians
- Are reviewed and updated periodically
- Guidelines are communicated to providers and, as appropriate, to enrollees
- Decisions with respect to utilization management, enrollee education, coverage of services and other areas in which the guidelines apply are consistent with the guidelines
An MA organization that suspends or terminates an agreement under which the physician provides services to MA plan enrollees must give the affected individual written notice of the following:
- The reasons for the action, including, if relevant, the standards and profiling data used to evaluate the physician and the numbers and mix of physicians needed by the MA organization.
- The affected physician’s right to appeal the action and the process and timing for requesting a hearing.
The MA organization must ensure that the majority of the hearing panel members are peers of the affected physician. An MA organization that suspends or terminates a contract with a physician because of deficiencies in the quality of care must give written notice of that action to licensing or disciplinary bodies or to other appropriate authorities. An MA organization and a contracted provider must provide at least 60 days written notice to each other before terminating the contract without cause.