TN 25 (07-15)

DI 39542.205 Contracting for Medical Provider Services -- DDS

Citations:

42 CFR 434.6

A. Introduction and guidelines on consultative examinations (CE)

The following sections provide guidelines for States wishing to contract with medical providers to perform CEs. This section includes:

  • the requirements for contracting out this function.

  • the elements of medical provider contracts and,

  • a model statement of work and contract language.

DDS must not treat the CE contractors as employees and consider certain factors.

  1. Initial proposal provides for:

  1. Management Summary including general background and organization of the firm, and services to be provided.

  2. Staffing Types and Qualifications of the physician(s) and other health care practitioners, who:

    • Must meet the licensing or certification requirements of the State (DI 22510.010); and

    • Are not currently excluded, suspended, or otherwise barred from participation in Medicare or Medicaid programs or any other Federal or federally assisted programs.

  3. Work plans for conducting training in performing CEs and preparing CE reports.

  4. Experience including a description of any similar contracts or work being performed for other organizations, affiliations and endorsements concerning work in the medical field.

B. Definitions of services

  1. Medical Provider means any provider of medical services, including:

    • individual practitioners, such as physicians and psychologists,

    • health care facilities such as group practices, labs, clinics and hospitals, and

    • volume providers.

  2. Volume Provider means a provider of medical services that specializes in performing CEs for state agencies and other insurers. Usually, but not necessarily, it includes a provider with estimated annual billings of $150,000 or more.

  3. Medical Provider Contract means a formal, written contract between the State and a provider of medical services to perform consultative examinations using physicians and other health care practitioners.

C. Policy on medical providers contracts

1. Contracting with medical providers

The State may contract with medical providers for consultative examinations. Such contracts must meet all the requirements set forth in DI 39542.001B. See POMS DI 39569.001 and DI 39569.100 for policy regarding avoiding contractor conflict of interest

2. Objectives of medical provider contracts

  1. Discount services - Consultative examinations with medical providers using state contracting rules should result in a substantially reduced cost of examinations.

  2. Improved quality - Formal contracts with medical providers should require specific performance and evaluation methods based on SSA standards for conducting consultative examinations.

  3. Timeliness of reports - Medical provider contracts should require time standards for the preparation and receipt of reports including incentive/penalty provisions.

  4. Establishing CE sources in underserved areas. A DDS may need to contract a CE source to travel in an area where the DDS has been unsuccessful in recruiting a local physician in a particular specialty.

3. Approval requirements

  1. Regional Commissioner (RC)  - Medical provider contracts require RC approval because they involve:

    • disclosure of information about disability claimants to a private source, and

    • creation of CE reports and maintenance of records on SSA claimants.

  2. The DDS must provide the contract template issued to the medical providers for RC approval prior to implementation. See DI 39542.010 for RC approval requirements.

4. Budget and fiscal requirements

The budget and fiscal requirements set out in DI 39542.025 are also applicable to this section.