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Contractual Relationships

Selective Contracting

  1. Those health delivery or financing systems that contract with selected physicians to furnish care should utilize selection criteria based primarily on professional competence and quality care. Any economic criteria used in selective contracting should have a demonstrated relationship to the quality and appropriateness of care and to professional competency.
  2. Health plans that contract with selected providers should have an established mechanism by which any provider willing to abide by terms of the plan contract could appeal a decision to deny the provider's application for participation in the plan.
  3. Health plans or networks should provide public notice within their geographic service areas when applications for participation are being accepted.
  4. Physicians should have the right to apply to any health care plan or network in which they desire to participate and to have that application judged on the basis of objective criteria that are available to both applicants and enrollees.
  5. Selective contracting decisions made by any health care delivery or financing system should be based on an evaluation of multiple criteria related to professional competency, quality of care, and the appropriateness by which medical services are provided. In general, no single criterion should provide the sole basis for selecting, retaining, or excluding a physician from a health care delivery or financing system.
  6. Prior to initiation of actions leading to termination of a physician's participation contract "for cause," the physician should be given notice specifying the grounds for termination, an opportunity for discussion, and an opportunity to initiate complete remedial activities, except in cases where harm to patients is imminent or an action by a state medical board or other government agency effectively limits the physician's ability to practice medicine.

(CPA Rpt D, A-93) (Reaffirmed A-17)

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Abbreviations for House of Delegates report origination:

EC – Executive Committee; BT – Board of Trustees; CPA – Council on Professional Affairs; JC – Judicial Council; CHS – Community and Health Services

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