Exhibit 10.172


 


 


 


AMENDMENT
NO. 1


 


The HMO IPA/Medical Group
Shared Savings Provider Agreement between California Physicians’ Service,
d.b.a.  Blue Shield of California
(“BSC-HMO”), and PROSPECT HEALTH SOURCE
MEDICAL GROUP (“Group”), with an effective date of July 1, 2003 is further amended effective July 1, 2003 as follows:


 


Amendment
1


 


Section 2.1l(c) is amended to
read in full as follows:


 


Group acknowledges that a
Member may request transfer between PCPs, and between Blue Shield medical
groups, in accordance with the Member’s applicable Health Services Contract and
Evidence of Coverage.  As appropriate,
Group agrees to accept the transfer of a Blue Shield member to Group at the
request of Blue Shield.  The effective
date of transfer, when requested during the course of treatment, during an
inpatient hospital stay, or during the third trimester of pregnancy, will be
the first of the month following:


 


•             Discharge
from hospital


•             Delivery


•             The
date it is medically appropriate to transfer the member’s care to his/her new
PCP as determined by the Plan.


 


Exceptions must be approved
by the regional Blue Shield Medical Director.


 


Amendment
2


 


Section 3.2(b) is amended to
read in full as follows:


 


(b) In the event of Group’s
continued or repeated failure to compensate Group Providers or other healthcare
providers within the time limits required by this Agreement as set forth in
Section 13.4, Blue Shield may elect to pay claims on behalf of Group and offset
the amount of such payments, along with a monthly administrative fee (not to
exceed 10% of monthly Capitation) from any amounts then or thereafter owed by
Blue Shield to Group, including capitation. 
Prior to any such action, Blue Shield shall have provided Group with
fifteen (15) days’ advance written notice of the repeated failures, which shall
serve as an opportunity to cure the noncompliance.  In the event that payment of such claims is of an urgent or
immediate nature as determined by Blue Shield, Blue Shield may elect to pay
such claims on behalf of Group without advance notice and may offset the amount
of such payments.


 


Amendment
3


 


Section 7.4 is amended to
read in full as follows:


 


Stop
Loss Coverage. During
the term of this Agreement, Group shall either obtain professional stop loss
coverage through Blue Shield under the terms and conditions set forth in
Exhibit H attached hereto or shall obtain professional stop loss coverage
either through a third party insurer or through a self-funding methodology
acceptable to Blue Shield.  Upon
request, certificates and other proof of such coverage shall be provided to
Blue Shield.  Group shall provide Blue
Shield with timely notice of cancellation of coverage or change in
carrier.  If Group elects to have Blue
Shield provide such stop loss coverage, by so indicating on the Signature Page
hereto, Blue Shield shall provide and charge Group for stop loss coverage as
set forth in Exhibit H.


 


Amendment
4


 


Section 14.10 is amended to
read in full as follows:


 


Non-Solicitation. During the term of this Agreement, and for
one (1) year thereafter, Group shall not solicit, induce, or encourage any
Member to disenroll from Blue Shield or select another health care service plan
for healthcare services.  Additionally,
during the term of this Agreement, and for one (1) year thereafter, Group shall
use best efforts to ensure that Group Providers do not solicit,


 












*** Confidential Information omitted and filed separately with the
Securities and Exchange Commission.


 


1

















 


induce, or encourage any Member to disenroll from Blue
Shield or select another health care service plan for healthcare services.  Notwithstanding the foregoing, Group and
Group Providers shall be entitled to freely communicate with Members regarding
any aspect of their health status or treatment.


 


Amendment
5


 


Exhibit F-l, Section 1 is amended to read in full as
follows:


 


Delegation
Responsibilities & Penalties. The capitation amounts paid
to Group by Blue Shield as set forth in Paragraph 7.1 (a) of this Agreement are
based on Blue Shield’s expectation that the Group accepts and will perform
delegation of the requirements set forth as Group’s responsibility in
Attachments I, II, III and IV of this Exhibit F.  The quality improvement and quality management obligations of Blue
Shield are not delegated to Group; however, Group shall have its own fully
functional Quality Management Program, as described in Attachment I, that is
cooperative with and integrated into the Blue Shield Quality Management
Program.  In accordance with paragraph
4.3 (c) of this Agreement, the net monthly capitation penalty reduction for any
de-delegated function shall be as follows:


 


	
   

  	
   

  	
  Commercial

  	
   

  	
  Blue
  Shield 65+

  	
   

  
	
  UM /
  Professional

  	
   

  	
  2.0

  	
  %

  	
  NA

  	
   

  
	
  UM / Shared
  Savings

  	
   

  	
  2.0

  	
  %

  	
  NA

  	
   

  
	
  Credentialing

  	
   

  	
  0.5

  	
  %

  	
  NA

  	
   

  
	
  Claims
  Processing

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Non-contracted
  Only Penalty

  	
   

  	
  0.7

  	
  %

  	
  NA

  	
   

  
	
  All Claims
  Penalty

  	
   

  	
  5.0

  	
  %

  	
  NA

  	
   

  
	
  Non-contracted
  Only Payment Withhold *

  	
   

  	
  8.5

  	
  %

  	
  NA

  	
   

  
	
  All Claims
  Payment Withhold

  	
   

  	
  85.0

  	
  %

  	
  NA

  	
   

  



 












* = Subject to actual
claims paid experience.


 


 


All other conditions and terms of this Agreement shall
remain the same.  When executed by both
parties, this Amendment shall be effective as of July 1, 2003.


 


	
  BLUE
  SHIELD OF CALIFORNIA

  	
  PROSPECT
  HEALTH SOURCE MEDICAL GROUP

  
	
   

  	
   

  
	
   

  	
   

  
	
  By:

  	
  /s/ LISA FARNAN

  	
   

  	
  By:

  	
  /s/ PETER GOLL

  	
   

  
	
   

  	
  LISA FARNAN

  	
   

  	
   

  	
  PETER GOLL

  	
   

  
	
   

  	
   

  
	
   

  	
   

  
	
   

  	
   

  	
  SENIOR VICE PRESIDENT,

  	
   

  
	
  Title:

  	
  VICE PRESIDENT, PROVIDER RELATIONS

  	
   

  	
  Title:

  	
  BUSINESS DEVELOPMENT

  	
   

  
	
   

  	
   

  
	
   

  	
   

  
	
  Date:

  	
  9-28-03

  	
   

  	
  Date:

  	
  9-17-03

  	
   

  
											



 


2