Exhibit 10.183


 


AMENDMENT TO THE

CALIFORNIACARE

MEDICAL SERVICES AGREEMENT

BETWEEN BLUE CROSS OF CALIFORNIA AND

STARCARE MEDICAL GROUP D.B.A. GATEWAY MEDICAL
GROUP, INC.


 


The Amendment to the CaliforniaCare Medical Services Agreement is
entered into at Woodland Hills, Los Angeles County, California, effective as of
January 1, 2002 between BLUE CROSS OF CALIFORNIA and Affiliates (“BLUE
CROSS”) and Starcare Medical Group d.b.a
Gateway Medical Group, Inc. (“PARTICIPATING MEDICAL GROUP”).


 


RECITALS


 


BLUE CROSS and PARTICIPATING MEDICAL GROUP have entered into a
CaliforniaCare Medical Services Agreement (the “Agreement”), effective
January 1, 2000, as amended.  The
parties have agreed to the following amended terms of the Agreement.


 


NOW, THEREFORE, IT IS AGREED:


 


Section 4.10                            Item A
of this Section shall be amended read as follows:


 


To accept any and all Members who select PARTICIPATING MEDICAL GROUP
until such time as PARTICIPATING MEDICAL GROUP shall have provided ninety (90)
days prior written notice to BLUE CROSS that it has reached its maximum
capacity as set forth in Section 16.08 herein.  PARTICIPATING MEDICAL GROUP shall be responsible for maintaining
sufficient professional and other resources to maintain its maximum capacity at
or above the specified level.  The
parties acknowledge their understanding that enrollment from individual
accounts, or changes in selection of PARTICIPATING MEDICAL GROUP by Members,
are not entirety within the control of BLUE CROSS.  Except as otherwise required by applicable law or regulation,
nothing in this Section shall require that BLUE CROSS reassign any Members
assigned to PARTICIPATING MEDICAL GROUP as of the effective date of the ninety
(90) day notice referenced herein.


 


Section 7.01                            This
Section shall be amended to read as follows:


 


Exhibits D, G and G-1 (all incorporated by reference herein), set forth
Capitation payments for new and renewing business.  The applicable Capitation payment for each Member assigned to
PARTICIPATING MEDICAL GROUP, shall be paid monthly, prorated in accordance with
Member eligibility.


 


Such Capitation payment shall be adjusted for Member age, sex and
Benefit Agreement in accordance with age, sex and plan relativities that have
been developed by BLUE CROSS based upon actuarial assumptions and BLUE CROSS'
utilization experience.  BLUE CROSS
reserves the right to adjust such relativity factors, upon contract renewal,
based upon BLUE CROSS experience.


 


Effective January 1, 2002 BLUE CROSS shall increase the base
Capitation rates in effect for 2001 for new and renewing Durational benefit
plans such as (but not limited to) “IC” (“Individual Durational”) and “L4”
(“Small Group Durational”) for PARTICIPATING MEDICAL GROUP BY ten percent (10.0%).


 












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


 


 

















 


Effective January 1, 2003 BLUE CROSS shall increase the base
Capitation rates in effect during 2002 for new and renewing business (excluding
Durational benefit plans, Blue Cross Plus, AIM, CalKids, and non-commercial
products such as Worker’s Compensation, Medi-Cal and Medicare+Choice) for
PARTICIPATING MEDICAL GROUP by ***.


 


Effective January 1, 2003 BLUE CROSS shall increase the base
Capitation rates in effect for 2002 new and renewing Durational benefit plans
such as Plans (but not limited to) “IC” (“Individual Durational”) and “L4”
(“Small Group Durational”) for PARTICIPATING MEDICAL GROUP by ***.


 


Effective January 1, 2004 BLUE CROSS shall increase the base
Capitation rates in effect during 2003 for new and renewing business (excluding
Durational benefit plans, Blue Cross Plus, AIM, CalKids, and non-commercial
products such as Worker’s Compensation, Medi-Cal and Medicare+Choice) for
PARTICIPATING MEDICAL GROUP by ***.


 


Effective January 1, 2004 BLUE CROSS shall increase the base
Capitation rates in effect for 2003 new and renewing Durational benefit plans
such as Plans (but not limited to) “IC” (“Individual Durational”) and “L4”
(“Small Group Durational”) for PARTICIPATING MEDICAL GROUP by ***.


 


Section 13.01                     This
Section shall be amended to read as follows:


 


The term of this Agreement shall be extended through December 31,
2004 (The period from January 1, 2002 through December 31, 2004 shall
hereafter be referred to as the “Extension Term”. ) Unless written notice of
intent not to renew or of intent to modify this Agreement as of the expiration
of the Extension Term or any subsequent renewal is provided at least one
hundred twenty (120) days prior to completion of the Extension Term or any
subsequent renewal period, this Agreement shall renew upon the same terms and
conditions for consecutive one year periods each year thereafter.


 


IN WITNESS WHEREOF, the parties hereto have executed this Amendment by
their officers thereunto duly authorized on the date and year first above
written.  Upon acceptance of the
parties, this Amendment shall become part of the Agreement effective
January 1, 2002 and all provisions of the Agreement not specifically
inconsistent herewith shall remain in full force and effect.


 


	
  BLUE CROSS OF CALIFORNIA

  	
  STARCARE MEDICAL GROUP d.b.a. GATEWAY
  MEDICAL GROUP, INC.

  
	
   

  	
   

  	
   

  
	
  Signature:

  	
  /s/ Barry Ford

  	
   

  	
  Signature:

  	
  /s/ Raj Takhar

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Name:

  	
  Barry Ford

  	
   

  	
  Name:

  	
  Raj Takhar

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Title:

  	
  Vice President

  	
   

  	
  Title:

  	
  Chief Executive Officer

  
	
   

  	
  Network Services

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Date:

  	
  7-24-02

  	
   

  	
  Date:

  	
  June 28, 2002

  



 


2

















 


AMENDMENT 


TO


CALIFORNIACARE MEDICAL SERVICES AGREEMENT


BETWEEN


BLUE CROSS OF CALIFORNIA


AND


STARCARE MEDICAL GROUP d.b.a. GATEWAY MEDICAL
GROUP, INC.


 


This Amendment
to the CaliforniaCare Medical Services Agreement is entered into at Woodland
Hills, Los Angeles County, California, and will be effective as of
January 1, 2002 between Blue Cross of California and its Affiliates (“BLUE
CROSS”) and Starcare Medical Group d.b.a. Gateway Medical Group, Inc.
(“PARTICIPATING MEDICAL GROUP”).


 


RECITALS


 


A.                                   BLUE CROSS and
PARTICIPATING MEDICAL GROUP have previously entered into a CaliforniaCare
Medical Services Agreement, effective January 1, 2000 (as amended, the
“Agreement”).


 


B.                                     The parties now
desire to amend the Agreement


 


NOW, THEREFORE, IT IS AGREED:


 


1.                                       Article II
of the Agreement is hereby amended as follows:


 


A.                                   The following
Sections are hereby deleted from Article II: 2.01 (Adjusted Per Member Per
Month Non-Capitated Expense), 2.03 (Age/Sex Factors), 2.06 (Attachment Point),
2.19 (Case Management Stop-Loss Threshold), 2.39 (Non-Capitated Performance
Settlement), 2.40 (Non-Capitated Performance Settlement Schedule), 2.46
(Outpatient Prescription Drug Expense), 2.47 (Outpatient Prescription Drug
Settlement), 2.48 (Outpatient Prescription Drug Settlement Schedule), 2.50 (Per
Member Per Month Non-Capitated Expense), 2.52 (Plan Factors), 2.58 (Region
Factor) and 2.62 (Stop-Loss Factor).


 


B.                                     The following sections
are hereby added to Article II:


 


2.67.1                  “Generic Outpatient Prescription
Drug(s)” means an outpatient prescription drug identified as a generic by
BLUE CROSS or First Data Bank and refers to an outpatient prescription drug
product having the same active ingredients as a brand or trade name product.


 


2.68.1                  “Generic Outpatient Prescription
Drug Utilization Incentive” means an amount paid to PARTICIPATING MEDICAL
GROUP based on the prescription of Generic Outpatient Prescription Drugs to
Members assigned to PARTICIPATING MEDICAL GROUP who have an outpatient
prescription drug benefit included in their Benefit Agreement.


 


2.69.1                  “Generic Outpatient Prescription
Drug Utilization Incentive Schedule” means a schedule of incentive
amounts associated with varied levels of prescription of Generic Outpatient
Prescription Drugs to Members assigned to PARTICIPATING MEDICAL GROUP who have
an outpatient prescription drug benefit included in their Benefit
Agreement.  This Schedule is set
forth in Exhibit H attached and incorporated herein.


 


1

















 


2.70.1                  “GOPDU Attachment Point” is
the point at which no Generic Outpatient Prescription Drug Utilization
Incentive shall be paid if PARTICIPATING MEDICAL GROUP’s GOPDU (as defined in
Section 10.01 of this Agreement) is less than or equal to that
amount.  The GOPDU Attachment Point is
shown on the Generic Outpatient Prescription Drug Utilization Incentive
Schedule, as set forth on Exhibit H attached and incorporated herein.


 


2.71.1                  “Scorecard Percentile Attachment
Point” is the point at which no Quality/Best Practices Scorecard Incentive
shall be paid if PARTICIPATING MEDICAL GROUP’s percentile ranking (rounded to
the nearest whole number) of its results on the Quality/Best Practices
Scorecard is less than or equal to such point. 
The Scorecard Percentile Attachment Point is shown on the Quality/Best
Practices Scorecard Incentive Schedule, as set forth on Exhibit I attached and
incorporated herein.


 


2.                                       Article IX
of the Agreement is hereby deleted and replaced in its entirety with the
following:


 


IX.                                NON-CAPITATED
SERVICES


 


9.01                           Billing
for Non-Capitated Services shall be as follows:


 


A.                                   The provider of
Non-Capitated Services may bill BLUE CROSS directly, in which case, BLUE CROSS
shall reimburse said provider within forty-five (45) working days following
receipt of a clean, undisputed claim accompanied by an authorization from
PARTICIPATING MEDICAL GROUP; or


 


B.                                     The provider of
Non-Capitated Services may bill PARTICIPATING MEDICAL GROUP, in which case,
PARTICIPATING MEDICAL GROUP shall bill BLUE CROSS for reimbursement.  BLUE CROSS shall reimburse PARTICIPATING
MEDICAL GROUP within forty-five (45) working days following BLUE CROSS receipt,
of a clean undisputed claim from PARTICIPATING MEDICAL GROUP, on the condition
that such claim shall be submitted to BLUE CROSS no later than twelve (12)
months after the date of service.  This
section shall only apply for the following Non-Capitated Services,
mammography services, DME, prosthetics and injectable medications (including
chemotheraphy drugs and infused substances).


 


In either case described above, BLUE CROSS shall pay contracting
providers at the rate negotiated between BLUE CROSS and said provider.  In the case of non-contracting providers,
BLUE CROSS shall pay the lesser of the actual billed charges, or the maximum
allowable rate according to the BLUE CROSS Customary and Reasonable charges, or
the rate arranged for by a CALIFORNIACARE Case Manager.


 


3.                                       Article X
of the Agreement is hereby deleted and replaced in its entirety with the
following:


 


X                                       GENERIC
OUTPATIENT PRESCRIPTION DRUG UTILIZATION


 


10.01                     Calculating
PARTICIPATING MEDICAL GROUP’s Generic Outpatient Prescription Drug Utilization
(“GOPDU”).


 


PARTICIPATING MEDICAL GROUP’s Generic Outpatient Prescription Drug
Utilization (“GOPDU”) is the quotient (rounded to the nearest whole number) of
(i) the


 


2

















 


number of Generic Outpatient Prescription Drugs prescribed during each
calendar year for Members assigned to PARTICIPATING MEDICAL GROUP who have an
outpatient prescription drug benefit included in their Benefit Agreement and
paid for by BLUE CROSS as specified below, divided by (ii) the total number of
outpatient prescriptions (generic, brand and trade name) prescribed during each
calendar year for Members assigned to PARTICIPATING MEDICAL GROUP who have an
outpatient prescription drug benefit included in their Benefit Agreement and
paid for by BLUE CROSS as specified below.


 


After the end of each calendar year BLUE CROSS shall calculate the
GOPDU for PARTICIPATING MEDICAL GROUP based on the prescriptions written for
Members assigned to PARTICIPATING MEDICAL GROUP who have an outpatient
prescription drug benefit included in their Benefit Agreement and the pharmacy
claims paid for such prescriptions during such prior calendar year through
March 31st after year-end. Beginning in year two (2) of this Agreement,
all outpatient drug prescriptions on pharmacy claims received after calculations
of the final Generic Outpatient Prescription Drug Utilization Incentive will be
included in the following year’s GOPDU calculation.


 


10.02                     Generic
Outpatient Prescription Drug Utilization Incentive Schedule


 


To be eligible for a Generic Outpatient Prescription Drug Utilization
Incentive PARTICIPATING MEDICAL GROUP must have participated in BLUE CROSS’s
CaliforniaCare network for a minimum of nine (9) months during the applicable
calendar year.


 


The Generic Outpatient Prescription Drug Utilization Incentive
Schedule set forth in Exhibit H will be the basis for determining any
Outpatient Prescription Drug Utilization Incentive to PARTICIPATING MEDICAL
GROUP.


 


10.03                     Calculating
the Outpatient Prescription Drug Utilization Incentive


 


If PARTICIPATING MEDICAL GROUP’s GOPDU is greater than the GOPDU
Attachment Point, as described in Exhibit H, PARTICIPATING MEDICAL GROUP will
be entitled to receive a Generic Outpatient Prescription Drug Utilization
Incentive, as determined in accordance with Exhibit H, provided that
PARTICIPATING MEDICAL GROUP meets the eligibility requirement set forth in
Section 10.02 above.


 


The amount of the Generic Outpatient Prescription Drug Utilization
Incentive will be based on the applicable PMPM incentive calculation under
Exhibit H multiplied by PARTICIPATING MEDICAL GROUP’s Member Months for the
calendar year for Members with outpatient prescription drug benefits in their
Benefit Agreement.  Within one hundred
eighty (180) days after the end of the “contract year” BLUE CROSS will pay any
Generic Outpatient Prescription Drug Utilization Incentive that is due
PARTICIPATING MEDICAL GROUP for the previous calendar year.  Notwithstanding the foregoing, in the event
this Agreement is terminated, BLUE CROSS shall calculate the Generic Outpatient
Prescription Drug Utilization Incentive in accordance with this Article X
and shall pay PARTICIPATING MEDICAL GROUP the applicable Generic Outpatient
Prescription Drug Utilization Incentive within 180 days after the date of
termination.  For purposes of
calculating the Generic Outpatient Prescription Drug Utilization Incentive,
“contract year” shall mean calendar year.


 


3

















 


PARTICIPATING
MEDICAL GROUP shall review such incentive payment and or any statement showing
the calculation of such incentive payment prepared by BLUE CROSS and shall
within forty-five (45) days of receipt, notify BLUE CROSS in writing of any
problem or discrepancy;  otherwise the
right to challenge the amount and/or the calculation of the incentive shall be
deemed waived by PARTICIPATING MEDICAL GROUP.


 


4.                                       Article
XI of the Agreement is hereby deleted and replaced in its entirety with the
following:


 


XI.                                QUALITY
BEST PRACTICES SCORECARD INCENTIVE


 


After the end
of each calendar year BLUE CROSS will evaluate PARTICIPATING MEDICAL GROUP’s
performance during such prior calendar year in certain areas related to quality
of care, compliance with administrative requirements and service delivery to
Members using a scorecard. 
PARTICIPATING MEDICAL GROUP will be notified of the scorecard parameters
and scoring methodology prior to the start of each year.


 


BLUE CROSS
will rank PARTICIPATING MEDICAL GROUP’s scorecard result with all other
participating medical groups’ scorecard results.  If PARTICIPATING MEDICAL GROUP’s percentile ranking (rounded to
the nearest whole number) exceeds the Scorecard Percentile Attachment Point set
forth on attached Exhibit I, PARTICIPATING MEDICAL GROUP will be entitled to
receive a Quality/Best Practices Scorecard Incentive calculated in accordance
with Exhibit I, provided that PARTICIPATING MEDICAL GROUP participated in BLUE
CROSS’s CaliforniaCare network for a minimum of nine (9) months during the
applicable calendar year.


 


If
PARTICIPATING MEDICAL GROUP’s member satisfaction survey results are not
available (but PARTICIPATING MEDICAL GROUP participated in such survey) or if
PARTICIPATING MEDICAL GROUP was ineligible to participate in such survey due to
a minimum membership requirement or if another component(s) of the scorecard
were not evaluated, BLUE CROSS will extrapolate PARTICIPATING MEDICAL GROUP’s
available scorecard result and then will rank such result with all other
participating medical groups’ scorecard results and use Exhibit I to determine
the amount of any Quality/Best Practices Scorecard Incentive, as set forth in
the above paragraph.  BLUE CROSS will
notify PARTICIPATING MEDICAL GROUP of its scorecard result and its ranking
after the end of the applicable calendar year.


 


Any
Quality/Best Practices Scorecard Incentive payable to PARTICIPATING MEDICAL
GROUP in accordance with the PMPM Quality/Best Practices Scorecard Incentive
Schedule shown in Exhibit I will be made within 180 days after the end of the
calendar year for which it is based. 
Notwithstanding the foregoing, in the event this Agreement is
terminated, BLUE CROSS shall calculate PARTICIPATING MEDICAL GROUP’s
Quality/Best Practices Scorecard Incentive payment in accordance with this
Article XI and shall pay any such incentive payment within 180 days after the
date of termination.  For purposes of
calculating the Quality/Best Practices Scorecard Incentive, “contract year”
shall mean calendar year.


 


PARTICIPATING
MEDICAL GROUP shall review such incentive payment and or any statement showing
the calculation of such incentive payment prepared by BLUE CROSS and shall
within forty-five (45) days of receipt, notify BLUE CROSS in writing of any
problem or discrepancy; otherwise the right to challenge the amount and or the
calculation of the incentive shall be deemed waived by PARTICIPATING MEDICAL
GROUP.


 


4

















 


EXHIBIT H


 


Generic Outpatient Prescription Drug
Utilization Incentive Schedule


 


Calculation
of Generic Outpatient Prescription Drug Utilization Incentive:


 


1)              Identify
the payment band that contains the PARTICIPATING MEDICAL GROUP’s Generic
Outpatient Prescription Drug Utilization (“GOPDU”).


2)              Calculate
the difference between PARTICIPATING MEDICAL GROUP’s GOPDU and the low value of
the payment band.


3)              Multiply
the result from Step 2 by the payment multiplier for the payment band.


4)              Add
the result from Step 3 to the minimum payment amount for the payment band to
get the PMPM GOPDU Incentive.


5)              Multiply
the PMPM GOPDU Incentive from Step 4 by the PARTICIPATING MEDICAL GROUP’s
Member Months for the calendar year (for Members with outpatient prescription
drug benefits in their Benefit Agreement) to calculate the GOPDU Incentive.


 


	
   

  	
   

  	
  GOPDU

  	
   

  	
  Payment

  Multiplier

  	
   

  	
  Minimum
  Payment

  PMPM

  	
   

  	
  Maximum
  Payment

  PMPM

  	
   

  
	
  Band

  	
   

  	
  Low

  	
   

  	
  High

  	
   

  	
   

  	
   

  	
   

  
	
  1

  	
   

  	
  0

  	
  %

  	
  47

  	
  %

  	
  $

  	
  0.00

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  2

  	
   

  	
  48

  	
  %*

  	
  51

  	
  %

  	
  $

  	
  12.50

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  3

  	
   

  	
  52

  	
  %

  	
  55

  	
  %

  	
  $

  	
  20.00

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  4

  	
   

  	
  56

  	
  %

  	
  59

  	
  %

  	
  $

  	
  17.50

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  5

  	
   

  	
  60

  	
  %

  	
  61

  	
  %

  	
  $

  	
  12.50

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  6

  	
   

  	
  64

  	
  %

  	
  >64

  	
  %

  	
  $

  	
  0.00

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 


PARTICIPATING MEDICAL GROUP’s
that have a GOPDU over 64% will
get a maximum payment of $2.50 PMPM based on the number of Members with
outpatient prescription drug benefits in their Benefit Agreement.


 


Example
of Generic Outpatient Prescription Drug Utilization Incentive Calculation:


 


Assume:  PARTICIPATING
MEDICAL GROUP has GOPDU of 62%; and there are 100,000 member months


(1)          Identify
the payment band that contains the PARTICIPATING MEDICAL GROUP’s GOPDU

PARTICIPATING MEDICAL GROUP’s GOPDU of 62%
falls between the low and high values of payment band 5


(2)          Calculate
the difference between PARTICIPATING MEDICAL GROUP’s GOPDU and the low value
for the payment band

62% - 60% = 2%


(3)          Multiply
the result from Step 2 by the payment multiplier for the payment band

2% x $12.50 = $0.25


(4)          Add
the result from Step 3 to the minimum payment amount for the payment band to
get the PMPM GOPDU Incentive

$2.00 + $0.25 = $2.25 PMPM GOPDU Incentive


(5)          Multiply
the PMPM GOPDU Incentive from Step 4 by the PARTICIPATING MEDICAL GROUP’s
Member Months for the calendar year to calculate the GOPDU Incentive

$2.25 PMPM x 100,000 member months = $225,000


 












* GOPDU Attachment Point


*** Confidential Treatment
Requested


 


H-1

















 


Gateway Medical Group


 


Notwithstanding
anything to the contrary herein, for Non-Durational.  Durational and BLUE CROSS PLUS plans members PARTICIPATING
MEDICAL GROUP’s Quality/Best Practices Scorecard Incentive payment shall be no
less than *** PMPM for calendar year 2002, *** PMPM for calendar year 2003 and
*** PMPM for calendar year 2004.


 


5.                                       Exhibit
F of the Agreement is hereby deleted in its entirety.


 


6.                                       Exhibits
H and I of the Agreement are hereby deleted and replaced in their entirety with
Exhibits H and I attached and incorporated herein.


 


Upon acceptance of the parties,
this Amendment, as of the date specified on page one hereof, shall become a
part of the Agreement, and all provisions of the Agreement not specifically
inconsistent herewith shall remain in full force and effect.


 


	
  BLUE CROSS OF CALIFORNIA

  	
   

  	
  STARCARE MEDICAL GROUP d.b.a

  GATEWAY MEDICAL GROUP, INC.

  
	
   

  	
   

  	
   

  
	
   

  	
  /s/ Barry
  Ford

  	
   

  	
   

  	
  /s/ Raj
  Takhar

  
	
  Signature

  	
   

  	
  Signature

  
	
   

  	
   

  	
   

  
	
   

  	
  Barry Ford

  	
   

  	
   

  	
  Raj Takhar

  
	
  Print Name

  	
   

  	
  Print Name

  
	
   

  	
   

  	
   

  
	
   

  	
  7-24-02

  	
   

  	
   

  	
  Chief
  Executive Officer 6/28/02

  
	
  Title

  	
  Date

  	
   

  	
  Title

  	
  Date

  
											



 


5

















 


EXHIBIT I


 


Quality/Best Practices Scorecard Incentive
Schedule


 


PARTICIPATING
MEDICAL GROUP can receive a maximum payment of $4.50 PMPM.


 


Calculation
of the Quality/Best Practices Scorecard Incentive Payment:


 


1)              Identify
the payment band that contains PARTICIPATING MEDICAL GROUP’s percentile ranking
(rounded to the nearest whole number) based its result from the Quality/Best
Practices Scorecard.


2)              Calculate
the difference between PARTICIPATING MEDICAL GROUP’s Quality/Best Practices
Scorecard percentile ranking (rounded to the nearest whole number) and the low
percentile ranking of the payment band.


3)              Multiply
the result from Step 2 by the payment multiplier for the payment band


4)              Add
the result from Step 3 to the minimum payment amount for the payment band to
get the PMPM Quality/Best Practices Scorecard Incentive.


5)              Multiply
the PMPM Quality/Best Practices Scorecard Incentive from Step 4 by
PARTICIPATING MEDICAL GROUP’s Member Months for the calendar year to calculate
the Quality/Best Practices Scorecard Incentive payment.


 


	
   

  	
   

  	
  Scorecard
  Percentile Ranking

  	
   

  	
  Payment

  Multiplier

  	
   

  	
  Minimum
  Payment

  PMPM

  	
   

  	
  Maximum
  Payment

  PMPM

  	
   

  
	
  Band

  	
   

  	
  Low

  	
   

  	
  High

  	
   

  	
   

  	
   

  	
   

  
	
  1

  	
   

  	
  0

  	
  %

  	
  19

  	
  %

  	
  $

  	
  0.00

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  2

  	
   

  	
  20

  	
  % *

  	
  39

  	
  %

  	
  $

  	
  6.25

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  3

  	
   

  	
  40

  	
  %

  	
  59

  	
  %

  	
  $

  	
  5.75

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  4

  	
   

  	
  60

  	
  %

  	
  79

  	
  %

  	
  $

  	
  5.50

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  5

  	
   

  	
  80

  	
  %

  	
  100

  	
  %

  	
  $

  	
  5.00

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 


Example
of Quality/Best Practices Scorecard Incentive Payment Calculation:


 


Assume:  PARTICIPATING MEDICAL GROUP’s
performance on the scorecard places it in the
90% percentile rank, and there are 100,000 member months


(1)          Identify
the payment band that contains PARTICIPATING MEDICAL GROUP’s percentile ranking
(rounded to the nearest whole number) based on its result from the Quality/Best
Practices Scorecard

PARTICIPATING MEDICAL GROUP’s ranking of 90%
falls between the low and high percentile rankings of payment band 5


(2)          Calculate
the difference between PARTICIPATING MEDICAL GROUP’s Quality/Best Practices
Scorecard percentile ranking (rounded to the nearest whole number) and the low
percentile ranking for the payment band.

90% - 80% = 10%


(3)          Multiply
the result from Step 2 by the payment multiplier for the payment band

10% x $5.00 = $0.50


(4)          Add
the result from Step 3 to the minimum payment amount for the payment band to
get the PMPM Quality/Best Practices Scorecard Incentive.

$0.50 + $3.50 = $4.00 PMPM Quality/Best
Practices Scorecard Incentive


(5)          Multiply
the PMPM Quality/Best Practices Scorecard Incentive from Step 4 by
PARTICIPATING MEDICAL GROUP’s Member Months for the calendar year to calculate
the Quality/Best Practices Scorecard Incentive payment.

$4.00 PMPM x 100,000 member months = $400,000
Quality/Best Practices Scorecard Incentive Payment


 












* Scorecard Percentile
Attachment Point


*** Confidential Treatment
Requested


 


I-1