Exhibit 10.2
INDEPENDENT PRACTICE ASSOCIATION PARTICIPATION AGREEMENT
This Independent Practice Association Participation Agreement (“Agreement”) is made and entered into by and between the party named on the signature page below (hereinafter referred to as“IPA”) and Humana Insurance Company, Humana Health Insurance Company of Florida, Inc., Humana Medical Plan, Inc. and their affiliates that underwrite or administer health plans (hereinafter referred to as“Humana”).
RELATIONSHIP OF THE PARTIES
| 1.1 | In performance of their respective duties and obligations hereunder,HumanaandIPA,andIPA’s respective employees and agents, are at all times acting and performing as independent contractors, and neither party, nor their respective employees and agents, shall be considered the partner, agent, servant, employee of, or joint venturer with, the other party. Unless otherwise agreed to herein, the parties acknowledge and agree that neitherIPAnorHumanawill be liable for the activities of the other nor the agents and employees of the other, including but not limited to, any liabilities, losses, damages, suits, actions, fines, penalties, claims or demands of any kind or nature by or on behalf of any person, party or governmental authority arising out of or in connection with: (i) any failure to perform any of the agreements, terms, covenants or conditions of this Agreement; (ii) any negligent act or omission or other misconduct; (iii) the failure to comply with any applicable laws, rules or regulations; or (iv) any accident, injury or damage to persons or property. Notwithstanding anything to the contrary contained herein,IPA further agrees to and hereby does indemnify, defend and hold harmlessHumanafrom any and all claims, judgments, costs, liabilities, damages and expenses whatsoever, including reasonable attorneys’ fees, arising from any acts or omissions in the provision byIPAof medical services to Members. This provision shall survive termination or expiration of this Agreement. |
| 1.2 | The parties agree thatHumana’saffiliates whose Members receive services hereunder do not assume Joint responsibility or liability between or among such affiliates for the acts or omissions of such other affiliates. |
SERVICES TO MEMBERS
| 2.1 | Subject at all times to the terms of this Agreement,IPAagrees to provide or arrange for medical and related health care services to individuals designated byHumana(herein referred to as“Members”) with an identification card or other means of identifying them as Members covered under a self-funded or fully insured health benefits plan to whichIPAhas agreed to participate as set forth in the product participation list attachment. | |
| 2.2 | IPAagrees to provideIPA’sservices to individuals covered under other third party payors’ (hereinafter referred to as“Payor”or“Payors”) health benefits contracts (hereinafter referred to as“Plan”or“Plans”) and agrees to comply with such Payors’ policies and procedures. For Covered Services rendered to such individuals,IPAacknowledges and agrees that all rights and responsibilities arising with respect to benefits to such individuals shall be subject to the terms of the Payor Plan covering such individuals. Individuals covered under such Plans will have an identification card as a means of identifying the Payor Plan which provides coverage. Such identification cards will display theHumanalogo and/or name. | |
| 2.3 | For Covered Services provided to those individuals identified in Section 2.2 above, Payor will make payments for Covered Services directly toIPAin accordance with the terms and conditions of this Agreement and the rates set forth in the payment attachment applicable to the Plan type of such individual.IPAagrees that in no event, including, but not limited to, nonpayment by Payor, or Payor’s insolvency, shallIPAbill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse againstHumanafor services provided byIPAto Plans’ members. This provision shall not prohibit collection byIPAfrom Plans’ members for non-covered services and/or member cost share amounts in accordance with the terms of the applicable member Plan. Payors Plans will provide appropriate steerage mechanisms including benefit designs and/or physician directory and web site listings to ensure their covered individuals will have incentives to utilizeIPA’s services. All obligations ofIPAunder this Agreement with respect toHumana’sMembers shall equally apply to the individuals identified in Section 2.2 above. |
1
THIRD PARTY BENEFICIARIES
| 3.1 | Except as is otherwise specifically provided in this Agreement, the parties have not created and do not intend to create by this Agreement any rights in other parties as third party beneficiaries of this Agreement, including, without limitation, Members. |
SCOPE OF AGREEMENT
| 4.1 | This Agreement sets forth the rights, responsibilities, terms and conditions governing: (i) the status ofIPA andIPA’semployees, subcontractors and/or independent contractors as health care providers (hereinafter referred to as“Participating Providers”) providing health care services; and (ii)IPA’s provision, or the arrangement for the provision, of professional medical services (hereinafter referred to as“IPA Services”) to Members. All terms and conditions of this Agreement which are applicable to“IPA”are equally applicable to each Participating Provider, unless the context requires otherwise. | |
| 4.2 | IPArepresents and warrants that it is authorized to negotiate terms and conditions of provider agreements, including this Agreement, and further to execute such agreements for and on behalf of itself and its Participating Providers.IPAfurther represents and warrants that Participating Providers will abide by the terms and conditions of this Agreement, including each ofIPA’semployed, subcontracted or independently contracted physicians. The parties acknowledge and agree that nothing contained in this Agreement is intended to interfere with or hinder communications betweenIPAand Members regarding the Members’ medical conditions or treatment options, andIPAacknowledges that all patient care and related decisions are the sole responsibility ofIPAandHumanadoes not dictate or control clinical decisions with respect to the medical care or treatment of Members. | |
| 4.3 | IPAacknowledges and agrees that with respect to self-funded groups, unless otherwise provided herein,Humana’sresponsibilities hereunder are limited to provider network administration and/or claims processing. |
SUBCONTRACTING PERFORMANCE
| 5.1 | IPAshall provide directly, or through appropriate agreements with physicians and other licensed health care professionals and/or providers, Physician Services for Members. It is understood and agreed thatIPAshall maintain written agreements with Participating Providers, if any, in a form comparable to, and consistent with, the terms and conditions established in this Agreement.IPA’sdownstream provider agreements, if any, shall include terms and conditions which comply with all applicable requirements for provider agreements under state and federal laws, rules and regulations. In the event of a conflict between the language of the downstream provider agreements and this Agreement, the language in this Agreement shall control. | |
| 5.2 | IPAshall provideHumanaan executed letter of agreement (in a form substantially similar to the form attached hereto as the letter of agreement attachment) for each Participating Provider who is a physician and who is subcontracted or independently contracted withIPAprior to the provision of services by such Participating Provider to Members. Such Participating Providers, if any, who do not execute a letter of agreement may not participate under this Agreement and may not be listed inHumana’sprovider directories. |
TERM AND TERMINATION
| 6.1 | The term of this Agreement shall commence on January 1, 2007 (the“Effective Date”).The initial term of this Agreement shall expire on July 31, 2011. This Agreement shall automatically renew for subsequent three (3) years terms unless either party provides written notice of non-renewal to the other party at least ninety (90) days prior to the end of the initial term or any subsequent renewal terms. |
2
| 6.2 | Humanamay terminate this Agreement, or any individual Participating Provider, immediately upon written notice toIPA,stating the cause for such termination, in the event: (i)IPA’s,or any individual Participating Provider’s, continued participation under this Agreement may adversely affect the health, safety or welfare of any Member or bringsHumanaor its health care networks into disrepute; (ii)IPAor any individual Participating Provider fails to meetHumana’scredentialing or re-credentialing criteria; (iii)IPAor any individual Participating Provider is excluded from participation in any federal health care program; (iv)IPA or any individual Participating Provider voluntarily or involuntarily seeks protection from creditors through bankruptcy proceedings or engages in or acquiesces to receivership or assignment of accounts for the benefit of creditors; or (v) Humana determines that IPA, or any of IPA or IPA’s Physicians’ employees, principals or financially related entities, have solicited, persuaded, induced, coerced, or otherwise caused the disenrollment of thirty-five or more Medicare Members assigned to an IPA Physician and such disenrollment meets the criteria set forth in section 23.12 of this Agreement (vi)Humana loses its authority to do business in total or as to any limited segment of business, but then only as to that segment; provided that in the event of an issue with respect to an individual Participating Provider only Humana’s termination shall be effective only as to the individual Participating Provider. | |
| 6.3 | In the event of a breach of this Agreement by either party, the non-breaching party may terminate this Agreement upon at least sixty (60) days prior written notice to the breaching party, which notice shall specify in detail the nature of the alleged breach; provided, however, that if the alleged breach is susceptible to cure, the breaching party shall have thirty (30) days from the date of receipt of notice of termination to cure such breach, and if such breach is cured, then the notice of termination shall be void of and of no effect. If the breach is not cured within the thirty (30) day period, then the date of termination shall be that date set forth in the notice of termination. Notwithstanding the foregoing, any breach related to credentialing or re-credentialing, quality assurance issues or alleged breach regarding termination byHumanain the event thatHumanadetermines that continued participation under this Agreement may affect adversely the health, safety or welfare of any Member or bringHumanaor its health care networks into disrepute, shall not be subject to cure and shall be cause for immediate termination upon written notice toIPA. | |
| 6.4 | IPAagrees that the notice of termination or expiration of this Agreement shall not relieveIPA’sobligation to provide or arrange for the provision of Physician Services through the effective date of termination or expiration of this Agreement. |
POLICIES AND PROCEDURES
| 7.1 | IPAagrees to comply withHumana’squality assurance, quality improvement, accreditation, risk management, utilization review, utilization management and other administrative policies and procedures established and revised byHumanafrom time to time and, in addition, those policies and procedures which are set forth inHumana’sPhysician’s Administration Manual, or its successor (hereinafter referred to as the���Manual”),and bulletins or other written materials that may be promulgated byHumanafrom time to time to supplement the Manual. The Manual and updated policies and procedures may be issued and distributed byHumanain electronic format. Paper copies may be obtained byIPAupon written request. Revisions to such policies and procedures shall become binding uponIPAthirty (30) days after such notice toIPAby mail or electronic means, or such other period of time as necessary forHumanato comply with any statutory, regulatory and/or accreditation requirements. |
CREDENTIALING AND PROFESSIONAL LIABILITY INSURANCE
| 8.1 | Participation under this Agreement byIPAand Participating Providers is subject to the satisfaction of all applicable credentialing and re-credentialing standards established byHumana. IPAshall provideHumana,or its designee, information necessary to ensure compliance with such standards at no cost toHumanaor its designee.IPAagrees to use electronic credentialing and recredentialing processes when administratively feasible.IPA,as applicable, and all Participating Providers providing Physician Services toHumanaMembers shall be credentialed in accordance withHumana’scredentialing process prior to receiving participating status withHumana. | |
| 8.2 | IPAshall maintain, at no expense toHumana,policies of comprehensive general liability, professional |
3
| liability, and workers’ compensation coverage as required by law, insuringIPAandIPA’s employees and agents against any claim or claims for damages arising as a result of injury to property or person, including death, occasioned directly or indirectly in connection with the provision of Physician Services contemplated by this Agreement and/or the maintenance ofIPA’sfacilities and equipment. Upon request,IPAshall provideHumanawith evidence of said coverage, of which minimum professional liability coverage shall be two hundred and fifty thousand dollars ($250,000) per occurrence and seven hundred and fifty thousand dollars ($750,000) in the aggregate, or as required by state law.IPAshall provideHumanawith written notice at least ten (10) days prior to any cancellations and/or modifications in the coverage.IPAshall within ten (10) business days following service uponIPA,or such other period of time as may be required by any applicable law, rule or regulation, notifyHumana in writing of any Member lawsuit alleging malpractice involving a Member. |
PROVISION OF MEDICAL SERVICES
| 9.1 | IPAshall provide Members all available medical services within the normal scope of and in accordance withIPA’s:(a) licenses and certifications, and (b) privileges to provide certain services based uponIPA’s qualifications as determined byHumana. IPAagrees to comply with all requests for information related toIPA’squalifications in connection with Humana’s determination whether to extend privileges to provide certain services and/or procedures to Members.IPAshall not bill, charge, seek payment or have any recourse against Humana or Members for any amounts related to the provision of Physician Services for which Humana has notifiedIPAthat privileges to perform such services have not been extended. | |
| 9.2 | IPAshall maintain all office medical equipment including, but not limited to, imaging, diagnostic and/or therapeutic equipment (hereinafter referred to as“Equipment”) in acceptable working order and condition and in accordance with the Equipment manufacturer’s recommendations for scheduled service and maintenance. Such Equipment shall be located inIPA’soffice locations that promote patient and employee safety.IPAshall provideHumanaor its agents with access to such Equipment for inspection and an opportunity to review all records reflecting Equipment maintenance and service history. Such Equipment shall only be operated by qualified technicians with appropriate training and required licenses and certifications. | |
| 9.3 | Equipment owned and/or operated byIPAshall comply with all standards for use of such Equipment and technician qualifications established byHumana. IPAagrees to comply with all requests for information related to Equipment andIPA’sand/orIPA’sstaff, qualifications for use of same. In the event: (i)IPA’s Equipment fails to meetHumana’sstandards; or (ii)IPAdeclines to comply withHumana’s standards for use of Equipment,IPAagrees that it will not use such Equipment while providing services to Members and shall not bill, charge, seek payment or have any recourse againstHumanaor Members for any amounts for services with respect to such Equipment. |
STANDARDS OF PROFESSIONAL PRACTICE
| 10.1 | Physician Services shall be made available to Members without discrimination on the basis of type of health benefits plan, source of payment, sex, age, race, color, religion, national origin, health status or disability.IPAshall provide Physician Services to Members in the same manner as provided to their other patients and in accordance with prevailing practices and standards of the profession. |
MEDICAL RECORDS
| 11.1 | IPA shall prepare, maintain and retain as confidential the medical records of all Members receiving Physician Services, and Members’ other personally identifiable health information received fromHumana,in a form and for time periods required by applicable state and federal laws, licensing requirements, accreditation and reimbursement rules and regulations to whichIPA is subject, and in accordance with accepted medical practice.IPAshall obtain authorization of Members permitting Humana, and/or any state or federal agency as permitted by law, to obtain a copy and have access, upon reasonable request, to any medical record of Member related to services provided byIPApursuant to applicable state and federal laws. Copies of such records for the purpose of claims processing shall be made and provided byIPAat no cost to Humana or the Member. |
4
| 11.2 | IPAandHumanaagree to maintain the confidentiality of information maintained in the medical records of Members, and information obtained from Humana through the verification of Member eligibility, as required by law. ThisSection 11shall survive expiration or termination of this Agreement, regardless of the cause. |
GRIEVANCE AND APPEALS PROCESS/BINDING ARBITRATION
| 12.1 | IPAshall cooperate and participate withHumanain grievance and appeals procedures to resolve disputes that may arise betweenHumanaand its Members. | |
| 12.2 | In the event of a dispute betweenIPAandHumanawhich is not resolved as set forth inSection 22 below, or which the parties cannot settle by mutual agreement, the dispute shall be resolved by binding arbitration, conducted by a single arbitrator selected by the parties from a panel of arbitrators proposed by the American Arbitration Association (“AAA”). This applies, without limitation, to any dispute arising out of the parties’ business relationship, including allegations or claims involving violations of state or federal laws or regulations. In the event the parties cannot agree on the arbitrator, then the arbitrator shall be appointed by the AAA. The arbitration shall be conducted in Miami- Dade County, FL, in accordance with and subject to the Commercial Arbitration Rules of the AAA then in effect, or under such other mutually agreed upon guidelines. Judgment upon the award rendered in any such arbitration may be entered in any court of competent jurisdiction, or application may be made to such court for judicial acceptance and enforcement of the award, as applicable law may require or allow. The submission of any dispute to arbitration shall not adversely affect either party’s right to seek preliminary injunctive relief with respect to an actual or threatened termination, repudiation or rescission of the Agreement. Except as expressly set forth inSection 22below, the costs of any arbitration proceeding(s) hereunder shall be borne equally by the parties, and each party shall be responsible for its own attorneys’ fees and such other costs and expenses incurred related to the proceedings. Arbitrations hereunder shall be conducted solely betweenIPAandHumana;class-based arbitration shall not be permitted. The parties agree this Agreement is a transaction involving interstate commerce and therefore that the Federal Arbitration Act, 9 U.S.C. §1 et seq. applies. |
USE OF IPA’S NAME
| 13.1 | Humanamay include the following information in any and all marketing and administrative materials published or distributed in any medium:IPA’sname, telephone number, address, office hours, type of practice or specialty, hospital affiliation, Internet web-site address, and the names of Participating Providers, including physicians providing care atIPA’soffice, and hospital affiliation, board certification, and other education and training history, if applicable, of Participating Providers.Humanawill provideIPA with access to such Information or copies of such administrative or marketing materials upon request. | |
| 13.2 | IPAmay advertise or utilize marketing materials, logos, trade names, service marks, or other materials created or owned byHumanaafter obtaining Humana’s written consent.IPAshall not acquire any right or title in or to such materials as a result of such permissive use. | |
| 13.3 | IPAagrees to allowHumanato distribute a public announcement ofIPA’saffiliation withHumana. |
PAYMENT
| 14.1 | IPAshall accept payment fromHumanafor those services for which benefits are payable under a Member’s health benefits contract (hereinafter referred to as “Covered Services”) provided to Member in accordance with the reimbursement terms in the payment attachment.IPAshall collect directly from Member any co-payment, coinsurance, or other member cost share amounts (hereinafter referred to as“Copayments”) applicable to the Covered Services provided and shall not waive, discount or rebate any such Copayments. Payments made in accordance with the payment attachment less the Copayments owed by Members pursuant to their health benefits contracts shall be accepted byIPAas payment in full from Humana for all Covered Services. This provision shall not prohibit collection byIPAfrom Member for any services not covered under the terms of the applicable Member health benefits contract. |
5
| 14.2 | IPAagrees that payment may not be made byHumanafor services rendered to Members which are determined byHumananot to be Medically Necessary.“Medically Necessary”(or“Medical Necessity”), unless otherwise defined in the applicable Member health benefits contract, means services or supplies provided by a licensed, certified or approved, as applicable, hospital, physician or other health care provider to identify or treat a condition, disease, ailment, sickness or bodily injury and which, in the opinion ofHumana,are: (i) consistent with the symptoms, diagnosis and treatment of the condition, disease, ailment, sickness or bodily injury; (ii) appropriate with regard to standards of accepted medical practice; (iii) not primarily for the convenience of the patient or the hospital, physician, or other health care provider; (iv) the most appropriate and cost-effective supply, setting, or level of service which safely can be provided to the patient; and (v) substantiated by records and documentation maintained by the provider of services. When applied to an inpatient, it further means that the patient’s symptoms or condition requires that the services or the supplies cannot be provided safely to the patient as an outpatient.IPA agrees that in the event of a denial of payment for Physician Services rendered to Members determined not to be Medically Necessary by Humana, thatIPAshall not bill, charge, seek payment or have any recourse against Member for such services. | |
| 14.3 | IPAagrees thatHumanamay recover overpayments made toIPAbyHumanaby offsetting such amounts from later payments toIPA,including, without limitation, making retroactive adjustments to payments toIPAfor errors and omissions relating to data entry errors and incorrectly submitted claims or incorrectly applied discounts.Humanashall provideIPAthirty (30) days advance written notice ofHumana’sintent to offset such amounts prior to deduction of any monies due. IfIPAdoes not refund said monies or request review of the overpayments described in the notice within thirty (30) days following receipt of notice fromHumana, Humanamay without further notice toIPAdeduct such amounts from later payments toIPA. Humanamay make retroactive adjustments to payments for a period not to exceed eighteen (18) months from original date of payment or such other period as may be required or allowed by applicable law. | |
| 14.4 | In the eventHumanahas access toIPA’s,or a Participating Provider’s, services through one or more other agreements or arrangements in addition to this Agreement,Humanawill determine under which agreement or arrangement payment for Covered Services will be made. | |
| 14.5 | Nothing contained in this Agreement is intended byHumanato be a financial incentive or payment that directly or indirectly acts as an inducement forIPAto limit Medically Necessary services. |
SUBMISSION OF CLAIMS
| 15.1 | IPAshall submit all claims toHumanaor its designee, as applicable, using the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) compliant 837 electronic format, or a CMS 1500 and/or UB-92, or their successors, within ninety (90) days from the date of service or within the time specified by applicable state law.Humanamay, in its sole discretion, deny payment for any claim(s) received byHumanaafter the later of ninety (90) days from the date of service, or the time specified by applicable state law.IPAacknowledges and agrees that at no time shall Members be responsible for any payments toIPAexcept for applicable Copayments and non-covered services provided to such Members | |
| 15.2 | Humanawill processIPAclaims which are accurate and complete in accordance withHumana’s normal claims processing procedures and applicable state and/or federal laws, rules and regulations with respect to the timeliness of claims processing. Such claims processing procedures may include, without limitation, automated systems applications which identify, analyze and compare the amounts claimed for payment with the diagnosis codes and which analyze the relationships among the billing codes used to represent the services provided to Members. These automated systems may result in an adjustment of the payment to theIPAfor the services or in a request, prior to payment, for the submission for review of medical records that relate to the claim.IPAmay request reconsideration of any adjustments produced by these automated systems by submitting a timely request for reconsideration toHumana. | |
| 15.3 | IPAshall use best efforts to submit all claims toHumanaby electronic means available and accepted as industry standards that are mutually agreeable, and which may include claims clearinghouses or electronic data interface companies used byHumana. IPAacknowledges thatHumanamay market certain products that will require electronic submission of claims in order forIPAto participate. |
6
COORDINATION OF BENEFITS
| 16.1 | When a Member has coverage, other than withHumana,which requires or permits coordination of benefits from a third party payor in addition toHumana, Humanawill coordinate its benefits with such other payor(s). In all cases,Humanawill coordinate benefits payments in accordance with applicable laws and regulations and in accordance with the terms of its health benefits contracts. When permitted to do so by such laws and regulations and by its health benefits contracts,Humanawill pay the lesser of: (i) the amount due under this Agreement; (ii) the amount due under this Agreement less the amount payable or to be paid by the other payor(s); or (iii) the difference between allowed billed charges and the amount paid by the other payor(s). In no event, however, willHumana,when its plan is a secondary payor, pay an amount, which, when combined with payments from the other payor(s), exceeds the rates set out in this Agreement; provided, however, if Medicare is the primary payer,Humanawill, to the extent required by applicable law, regulation or Centers for Medicare and Medicaid Services (“CMS”) Office of Inspector General (“OIG”) guidance, payIPAan amount up to the amountHumanawould have paid, if it had been primary, toward any applicable unpaid Medicare deductible or coinsurance. |
NO LIABILITY TO MEMBER FOR PAYMENT
| 17.1 | IPAagrees that in no event, including, but not limited to, nonpayment byHumana, Humana’s insolvency or breach of this Agreement, shallIPAor any Participating Provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against Members or persons other thanHumana(or the payor issuing the health benefits contract administered byHumana)for Covered Services provided byIPA.This provision shall not prohibit collection byIPAfrom Member for any non-covered service and/or Copayments in accordance with the terms of the applicable Member health benefits contract. | |
| 17.2 | IPAfurther agrees that: (i) this provision shall survive the expiration or termination of this Agreement regardless of the cause giving rise to expiration or termination and shall be construed to be for the benefit of the Member; (ii) this provision supersedes any oral or written contrary agreement now existing or hereafter entered into betweenIPAand Member or persons acting on their behalf; and (iii) this provision shall apply to all employees, agents, trustees, assignees, subcontractors, and independent contractors ofIPA,andIPAshall obtain from such persons specific agreement to this provision. | |
| 17.3 | Any modification to thisSection 17shall not become effective unless approved by the Commissioner of Insurance, in the event such approval is required by applicable state law or regulation, or such changes are deemed approved in accordance with state law or regulation. |
ACCESS TO INFORMATION
| 18.1 | IPAagrees thatHumana,or any state or federal regulatory agency as required by law, shall have reasonable access and an opportunity to examineIPA’sfinancial and administrative records as they relate to services provided to Members during normal business hours, on at least seventy-two (72) hours advance notice, or such shorter notice as may be imposed onHumanaby a federal or state regulatory agency or accreditation organization. |
NEW PRODUCT INTRODUCTION
| 19.1 | From time to time during the term of this Agreement,Humanamay develop or implement new products. ShouldHumanaoffer participation in any such new product toIPA, IPAshall be provided with sixty (60) days’ written notice prior to the implementation of such new product. IfIPAdoes not object in writing to its participation in such new product within such sixty (60) day notice period,IPAshall be deemed to have accepted participation in the new product. In the eventIPA objects to its participation in a new product, the parties shall confer in good faith to reach agreement on the terms ofIPA’sparticipation. If agreement on such new product cannot be reached, such new product shall not apply to this Agreement.Humanamay in its discretion, establish, develop, manage and market provider networks in whichIPAmay not be selected to participate. |
7
ASSIGNMENT AND DELEGATION
| 20.1 | The assignment byIPAof this Agreement or any interest hereunder shall require notice to and the written consent ofHumana.As used in this paragraph, the term “assignment” shall also include a change of control inIPA’spractice by merger, consolidation, transfer, or the sale of thirty-three percent (33%) or more stock or other ownership interest inIPA’s practice. Any attempt byIPAto assign this Agreement or any interest hereunder without complying with the terms of this paragraph shall be void and of no effect, andHumana,at its option, may elect to terminate this Agreement upon thirty (30) days written notice toIPA, without any further liability or obligation toIPA. Humanamay assign this Agreement in whole or in part to any purchaser of or successor to the assets or operations ofHumana,or to any affiliate ofHumana,provided that the assignee agrees to assumeHumana’sobligations under this Agreement. Upon notice of an assignment byHumana, IPAmay terminate this Agreement upon thirty (30) days written notice toHumana. |
COMPLIANCE WITH REGULATORY REQUIREMENTS
| 21.1 | IPAacknowledges, understands and agrees that this Agreement may be subject to the review and approval of state regulatory agencies with regulatory authority over the subject matter to which this Agreement may be subject. Any modification of this Agreement requested by such agencies or required by applicable law or regulations shall be incorporated herein as provided inSection 23.10,of this Agreement. | |
| 21.2 | IPAandHumanaagree to be bound by and comply with the provisions of all applicable state and/or federal laws, rules and regulations. The alleged failure by either party to comply with applicable state and/or federal laws, rules or regulations shall not be construed as allowing either party a private right of action against the other in any court, administrative or arbitration proceeding in matters in which such right is not recognized or authorized by such law or regulation.IPAand Participating Providers agree to procure and maintain for the term of this Agreement all license(s) and/or certification(s) as is required by applicable law andHumana’spolicies and procedures.IPAshall notifyHumanaimmediately of any changes in licensure or certification status ofIPAor Participating Providers. IfIPAor any individual Participating Provider violates any of the provisions of applicable state and/or federal laws, rules and regulations, or commits any act or engages in conduct for whichIPA’sor Participating Providers’ professional licenses are revoked or suspended, or otherwise is restricted by any state licensing or certification agency by whichIPAor Participating Providers are licensed or certified,Humanamay immediately terminate this Agreement or any individual Participating Provider, provided that in the event of an issue with respect to an individual Participating Provider only, Humana’s termination shall be effective only as to the individual Participating Provider. |
DISPUTE RESOLUTION/LIMITATIONS ON PROCEEDINGS
| 22.1 | IPAandHumanaagree that in the event they are unable to resolve disputes that may arise with respect to this Agreement,IPAwill first exhaust any internalHumanaadministrative review or appeal mechanisms prior to submitting any matters to binding arbitration. | |
| 22.2 | IPAmay contest the amount of the payment, denial or nonpayment of a claim only within a period of eighteen (18) months following the date such claim was paid, denied or not paid by the required date byHumana.In order to contest such payments,IPAshall provide toHumana, at a minimum, in a clear and acceptable written format, the following information: Member name and identification number, date of service, relationship of the Member to the patient, claim number, name of the provider of the services, charge amount, payment amount, the allegedly correct payment amount, difference between the amount paid and the allegedly correct payment amount, and a brief explanation of the basis for the contestation.Humana will review such contestation(s) and respond toIPAwithin sixty (60) days of the date of receipt byHumanaof such contestation. In the event a dispute about the contestations cannot be resolved by mutual agreement or as set forth above, either party may submit the matter for non-binding mediation to a board certified mediator selected by the parties or from a panel of mediators proposed by the AAA. In the event the parties cannot agree on the mediator, then the mediator shall be appointed by the AAA. The mediation shall occur within sixty (60) days following the submission byHumanaof the matter to the mediator. If the mediation does not occur within such time period or neither party submits the dispute to |
8
| mediation, either party may submit the dispute to binding arbitration in accordance withSection 12.2above. The dispute shall not be submitted to binding arbitration by either party prior to the expiration of the sixty (60) day period allowed for Humana’s response to the contestation. Except as set forth below, the cost of the mediation shall be divided equally between the parties. The parties shall first exhaust the contestation procedures described above prior to submitting the contestations dispute to binding arbitration in accordance withSection 12.2above. In the event of a determination, following mediation or the arbitration proceedings described inSection 12.2above, that the claims in dispute, in the aggregate, were processed and paid correctly,IPAshall, upon request ofHumana, reimburseHumana,the out of pocket costs and expenses, and attorneys fees incurred byHumanathat are attributable to the mediation or arbitration proceeding. In the event of a determination, following mediation or the arbitration proceedings described inSection 12.2 above, that the claims in dispute, in the aggregate, were not processed and paid correctly byHumana, Humanashall, upon request ofIPA,reimburseIPA’sout of pocket costs and expenses, and attorneys fees incurred byIPAthat are attributable to the mediation or arbitration proceeding. |
MISCELLANEOUS PROVISIONS
| 23.1 | SEVERABILITY.If any part of this Agreement should be determined to be invalid, unenforceable, or contrary to law, that part shall be reformed, if possible, to conform to law, and if reformation is not possible, that part shall be deleted, and the other parts of this Agreement shall remain fully effective. | |
| 23.2 | GOVERNING LAW.This Agreement shall be governed by and construed in accordance with the applicable laws of the State of Florida. The parties agree that applicable state and/or federal laws and/or regulations may make it necessary to include in this Agreement specific provisions relevant to the subject matter contained herein. Such state law provisions, if any, are set forth in the state law coordinating provisions attachment hereto. Such federal law provisions, if any, are set forth in the Medicare Advantage provisions attachment hereto. The parties agree to comply with any and all such provisions and in the event of a conflict between the provisions in the state law coordinating provisions attachment and/or the Medicare Advantage provisions attachment and any other provisions in this Agreement, the provisions in those attachments, as applicable, shall control. In the event that state and/or federal laws and/or regulations enacted after the Effective Date expressly require specific language be included in this Agreement, such provisions are hereby incorporated by reference without further notice by or action of the parties and such provisions shall be effective as of the effective date stated in such laws, rules or regulations. | |
| 23.3 | WAIVER.The waiver, whether express or implied, of any breach of any provision of this Agreement shall not be deemed to be a waiver of any subsequent or continuing breach of the same provision. In addition, the waiver of one of the remedies available to either party in the event of a default or breach of this Agreement by the other party shall not at any time be deemed a waiver of a party’s right to elect such remedy at any subsequent time if a condition of default continues or recurs. | |
| 23.4 | NOTICES.Any notices, requests, demands or other communications, except notices of changes in policies and procedures pursuant toSection 7,required or permitted to be given under this Agreement shall be in writing and shall be deemed to have been given: (i) on the date of personal delivery; or (ii) provided such notice, request, demand or other communication is received by the party to which it is addressed in the ordinary course of delivery: (a) on the third day following deposit in the United States mail, postage prepaid or by certified mail, return receipt requested; (b) on the date of transmission by facsimile transmission; or (c) on the date following delivery to a nationally recognized overnight courier service, each addressed to the other party at the address set forth below their respective signatures to this Agreement, or to such other person or entity as either party shall designate by written notice to the other in accordance herewith.Humanamay also provide such notices toIPAby electronic means to the e-mail address ofIPAset forth on the Cover Sheet to this Agreement or to other e-mail addressesIPAprovides toHumanaby notice as set forth herein. Unless a notice specifically limits its scope, notice to any one party included in the term“IPA”or “Humana” shall constitute notice to all parties included in the respective terms. | |
| 23.5 | CONFIDENTIALITY. IPAagrees that the terms of this Agreement and information regarding any dispute arising out of this Agreement are confidential, and agrees not to disclose the terms of this Agreement nor |
9
| information regarding any dispute arising out of this Agreement to any third party without the express written consent ofHumana,except pursuant to a valid court order, or when disclosure is required by a governmental agency. Notwithstanding anything to the contrary herein, the parties acknowledge and agree thatIPAmay discuss the payment methodology included herein with Members requesting such information. | ||
| 23.6 | COUNTERPARTS, HEADINGS AND CONSTRUCTION.This Agreement may be executed in one or more counterparts, each of which shall be deemed an original, and all of which together constitute one and the same instrument. The headings in this Agreement are for reference purposes only and shall not be considered a part of this Agreement in construing or interpreting any of its provisions. Unless the context otherwise requires, when used in this Agreement, the singular shall include the plural, the plural shall include the singular, and all nouns, pronouns and any variations thereof shall be deemed to refer to the masculine, feminine or neuter, as the identity of the person or persons may require. It is the parties desire that if any provision of this Agreement is determined to be ambiguous, then the rule of construction that such provision is to be construed against its drafter shall not apply to the interpretation of the provision. | |
| 23.7 | INCORPORATION OF ATTACHMENTS.All attachments attached hereto are incorporated herein by reference, (e.g. PAYMENT, DELEGATION OF UTILIZATION REVIEW/MANAGEMENT) | |
| 23.8 | FORCE MAJEURE.Neither party to this Agreement shall be deemed to breach its obligations under this Agreement if that party’s failure to perform under the terms of this Agreement is due to an act of God, riot, war or natural disaster. | |
| 23.9 | ENTIRE AGREEMENT.This Agreement, including the attachments, addenda and amendments hereto and the documents incorporated herein, constitutes the entire agreement betweenHumanaandIPAwith respect to the subject matter hereof, and it supersedes any prior or contemporaneous agreements, oral or written, betweenHumanaandIPA. | |
| 23.10 | MODIFICATION OF AGREEMENT.This Agreement may be amended in writing as mutually agreed upon byIPAandHumana.In addition,Humanamay amend this Agreement upon sixty (60) days’ written notice toIPA.Failure ofIPAto object in writing to such amendment during the sixty (60) day notice period shall constitute acceptance of such amendment byIPA. | |
| 23.11 | SARBANES-OXLEY.Humana acknowledges that IPA is subject to the provisions of the Sarbanes-Oxley Act of 2002 and the rules, regulations and interpretations promulgated thereunder (the “Sarbanes-Oxley Act”). In order to assist IPA with its compliance with the provisions of Section 404 of the Sarbanes-Oxley Act, if Humana obtains Type 2 Statement of Auditing Standards 70 reports (“SAS 70 Reports”) from their independent auditors regarding the operating effectiveness of Humana’s internal controls over financial reporting (the “Humana Controls”), Humana will provide IPA with a copy upon request. If Humana does not provide IPA with current SAS 70 Reports, solely for the purpose of assessing Humana Controls, Humana will make available to IPA and its independent auditors information regarding the Humana Controls as IPA may reasonably request upon reasonable advance notice. | |
| 23.12 | LIQUIDATED DAMAGES.IPA acknowledges and shall require lPA physicians to acknowledge that HUMANA has invested and will invest substantial resources including funds, time, effort and goodwill in building a roll of Medicare Members to be treated by IPA Physicians. Therefore, IPA agrees that IPA and IPA Physicians, or any of IPA or IPA Physicians’ employees, principals or financially related entities, shall not solicit, persuade, induce, coerce or otherwise cause the disenrollment of any Medicare Member at anytime, directly or indirectly. If thirty-five (35) or more Medicare Members assigned to an individual IPA Physician disenroll from HUMANA due to IPA or IPA Physicians’ directly or indirectly soliciting, persuading, inducing, coercing or otherwise causing the disenrollment of such Medicare |
10
| Members to be treated by IPA or any IPA Physicians or IPA/IPA Physicians’ employees, principals or other financially related entity under some other prepaid health care benefit plan other than HUMANA’s IPA shall pay HUMANA the amount of three thousand dollars ($3000.00) for each disenrolled Medicare Member who is treated by IPA, or any IPA Physicians or IPA/IPA Physicians’ employees, principals or any financially related entity. IPM hereby agrees and shall require IPA Physicians hereby to agree that this amount is not a penalty and constitutes liquidated damages in as such as the actual damages are not and cannot be ascertained at the time of the execution of this Agreement. IPA and IPA Physicians understand that this liquidated damages clause does not apply to or require payment from the Medicare Members under any circumstance. HUMANA agrees with IPA and IPA Physicians that this paragraph shall not be applicable in the case of any Medicare Member who disenrolls and is treated by a IPA Physician or anyone else on a non-prepaid and non-capitated fee-for-service basis as a private patient. In addition, Medicare Members who were patients prior to IPA Physician’s participation as a HUMANA Participating Provider, are excluded from this provision, if the IPA and/or IPA Physician can furnish documentation to HUMANA in the form of a list of his/her patients prior to becoming a HUMANA Participating Provider. IPA and IPA Physicians have the obligation to and agree to notify HUMANA immediately of the name of any Medicare Member or former Medicare Member treated by a IPA Physician or any other person covered by this provision. This paragraph shall survive for twelve (12) months following the termination or expiration of this Agreement regardless of the cause giving rise to termination. | ||
| 23.13 | NON-COMPETE: During the term of this Agreement and for the one (1) year period following termination of this Agreement, regardless of the cause giving rise to such termination, IPA agrees and shall require IPA Physicians to agree that it is in their respective legitimate business interests to enter into the following restrictive covenants, such interests being the preservation and fostering of goodwill and the substantial business and other relationships the parties have with their respective Members, customers, providers, patients and others. Therefore, the parties agree to the following: | |
| 23.13.1 | IPA agrees and shall require IPA Physicians to agree not to, directly or indirectly: (I) engage in any activities which are in competition with HUMANA’s comprehensive health insurance, health maintenance organization or comprehensive benefits plans business, including but not limited to obtaining a license to become a managed health care plan offering HMO or POS products; or (II) acquire, manage, establish or otherwise have any direct or indirect interest in any provider sponsored organization or network (such organization or network commonly and hereinafter refer to as a “PSN”), as now or in the future defined or authorized by CMS or any other federal or state agency or enabling legislation or regulation, for the purpose of administering, developing, implementing or selling Medicare, Medicaid or other government sponsored health insurance or benefit plans; or (III) contract or affiliate with another party which is a licensed managed care organization, where such affiliation or contract is for the purpose of offering and sponsoring HMO or POS Products, and where IPA and/or IPA Physicians obtain an ownership interest in the HMO or POS managed health care product to be marketed at the same office sites where services are to be provided to HUMANA Members and as listed in IPA Information Attachment of this Agreement or at other office sites within a five (5) mile radius of said office sites listed in IPA Information Attachment. | |
| 24.1. | CONFLICT OF INTEREST: IPA hereby represents and warrants that except as disclosed inConflict of lnterest Disclosure Form,IRA, including all Principals of IPA, and IPA Physicians do not have an interest, directly or indirectly, as a partner, office, member, director, including but not limited medical director, shareholder of more than five percent (5%) of the entity’s outstanding shares, financial, business and/or medical advisor, employee or in any other employed managerial, advisory, fiscal, ownership or control capacity, in any other health maintenance organization, prepaid health plan or similar entity providing prepaid health services, and/or any affiliated companies thereof, hereafter referred to as“Competitive Plan”. |
11
| 24.2 | IPA agrees that IPA has a continuing obligation to update any and all information in Conflict of Interest Disclosure Form and to notify HUMANA immediately of any changes herein. |
12
IN WITNESS WHEREOF,the parties have the authority necessary to bind the entities identified herein and have executed this Agreement to be effective as of the Effective Date.
| IPA/AUTHORIZED SIGNATORY | HUMANA | |||||||||||||
| Signature: | Signature: | |||||||||||||
| Printed Name: | Printed Name: | |||||||||||||
| Title: | Title: | |||||||||||||
| Date: | Date: | |||||||||||||
Address For Notice:
IPA: | HUMANA: | |
| Continucare Medical Management, Inc. | Copy to: | |
| 7200 Corporate Center Drive | Humana Inc. | |
| Suite 600 | P.O. Box 1438 | |
| Miami, Fl 33126 | Louisville, Kentucky 40201-1438 | |
| Attn: President | Attn: Law Department |
13