Process for Requesting Termination or Transfer
Provider Type
- Participating Physician Groups (PPG)
All Levels of Behavior
Formally document each incident of unacceptable behavior on the Transfer/Termination (T/T) Incident Report form (PDF) and send the T/T Request Unit. Include documentation of any counseling sessions with the member regarding unacceptable behavior and any follow-up written notifications. If the counseling session is documented in the member's medical record by the physician, physician assistant (PA) or registered nurse practitioner (RNP), attach a copy of this documentation to the T/T Incident Report. Incidents of unacceptable behavior can often occur in rapid succession, so it is important that the participating physician group (PPG) remain current in its discussions and notification letters. Incidents must be documented as they occur, not retroactively.
When a primary care physician (PCP) or specialist determines that he or she is unable to continue to provide care to a member because the patient-physician relationship has been compromised and mutual trust and respect are lost, a just-cause member transfer may be appropriate. In the United States, the treating physicians and PPGs must always work within the code of ethics established through the American Medical Association (AMA). For information regarding the AMA code of ethics, refer to the AMA website at www.ama-assn.org.
Under the code of ethics, the physician must provide the member with notice prior to discontinuing as the treating physician to enable the member to contact the plan and make alternate care arrangements. However, prior to sending such notice, physicians must also coordinate such transfers with their PPGs' administration department. The plan conducts a fair investigation of the facts before any involuntary transfer for any reason is carried out.
Legally, the plan cannot consider termination unless the PPG or PCP follows the proper procedures outlined below for the applicable level of behavior. The plan must have time for follow-up communication with the member and must allow the member a reasonable time to respond.
- When sending the T/T Request Unit, the notification letters and T/T Incident Report, include all documentation relating to the incident. The plan and the PPG must have thorough documentation of each occurrence as a former member may take legal action. To ensure that all documentation is current, it is important for the PCP to go through the PPG administration department in contacting the plan.
- Any T/T Incident Report received in the T/T Request Unit without a copy of the member notification letter is considered incomplete and is returned to the originating PCP or PPG
- The T/T Request Unit staff assesses the member's warning level and any possible transition of care concerns.
- A copy of the T/T Incident Report is forwarded to the appropriate provider relations & contracting specialist (formally provider network administrator).
- The plan must receive the member's statement within 20 calendar days from the time of the plan's receipt of the PPG's notification letter to allow the plan an opportunity to mediate the situation informally
For commercial lines of business, these behaviors can result in a transfer, but not in termination of coverage, except in the case of fraudulent activity.
Level A Behavior
Level A behavior is:
- Failure to pay the required copayments after at least two billings. The copayment balance (if applicable) must exceed $50 before the plan considers transfer of the member.
- Three missed appointments within 12 consecutive months without timely cancellation.
Level A behavior must occur at least three separate times within 12 consecutive months and persist despite the following warnings of both the participating physician group (PPG) and the plan to warrant termination:
- First occurrence of level A behavior - The PPG must counsel the member, including asking for the member's perspective, and document the counseling session. A letter must be written to the member indicating that such behavior is unacceptable. If the member is under age 18, the subscriber must be notified of the incident. It is recommended that the letter be sent by registered mail with return receipt requested. The PPG is required to keep a copy of the letter and the Transfer/Termination (T/T) Incident Report (PDF).
In addition, a copy of the letter, documentation and the T/T Incident Report must be mailed or faxed to the T/T Request Unit.
The provider relations & contracting specialist (formally provider network administrator) must receive a copy of the T/T Incident Report.
- Second occurrence of level A behavior - The PPG takes the same action as with the first occurrence. At this point, the plan sends the member a warning letter outlining the behavior problem and the possible consequences if the behavior persists.
- Third occurrence of level A behavior - The PPG may request, in writing, a transfer or termination of the subscriber or member from the contract. The plan reviews the PPG documentation outlining the continued unacceptable behavior.
The plan is allowed up to 60 calendar days to mediate the situation again on receipt of the second warning letter.
For commercial lines of business, these behaviors can result in a transfer, but not in termination of coverage.
Level B Behavior - HMO & Medicare
Level B behavior is:
- A provider's request to transfer a member to another provider if the member and current provider cannot agree on a treatment plan (note: members have the right to refuse care), and after reasonable notification is made to the member and an alternate provider is obtained
- Disruptive or abusive behavior exhibited to the primary care physician (PCP) office staff, a referral physician, or a hospital emergency department. This behavior must be deemed so disruptive or abusive that the physicians involved determine that the member-physician relationship has deteriorated to such a level that it cannot be resolved satisfactorily to both parties
Level B behavior must occur twice to two different providers in the participating physician group (PPG) within 12 consecutive months to warrant termination from the PPG. Upon first occurrence, the PPG must counsel the member, including asking for the member's perspective, and write to the member stating that such behavior is unacceptable. The counseling session must be documented. Mail or fax a copy of the letter, documentation of the incident and a copy of the Transfer/Termination (T/T) Incident Report (PDF) to the T/T Request Unit.
A copy of the T/T Incident Report is sent to the provider relations & contracting specialist (formally provider network administrator). The PPG keeps a copy of the letter and the T/T Incident Report. The plan sends the member a warning letter, outlining the behavior problem and the possible consequence (termination) if such behavior persists.
For Level A or B behavior, the plan is allowed up to 60 calendar days after receipt of the request for transfer or termination (sent only after the above procedure for the previous occurrence is followed) before the subscriber is officially notified of the transfer or termination. This is to allow the plan adequate time to:
- Review the supporting documentation.
- Allow legal counsel to review the case, if needed.
- Attempt another informal transfer or removal of the member.
- Allow the Case Management Department and regional medical director review as appropriate.
For commercial lines of business, these behaviors can result in a transfer, but not in termination of coverage.
Level C Behavior
Level C behavior is:
- Fraudulently applying for any benefits under the plan contract.
- Dangerous behavior exhibited in the course of seeking or receiving care (for example, threatened or attempted physical abuse of participating physician group (PPG) staff or other patients). There must be an eyewitness to the occurrence who is willing to document the incident in writing.
- Receipt of a notice of a subscriber's intent to pursue legal action. Refer to the Just-Cause Request to Transfer discussion under the Guidelines for Transfer discussion for additional information.
Level C behavior need only occur once for the PPG to request immediate transfer or termination. The PPG must formally document the incident, including written notification to the member. Mail or fax the PPG's transfer or termination request with all supporting documentation to the Transfer/Termination (T/T) Request Unit.
As this is the plan's first awareness of a problem with the subscriber or member, and given the seriousness of level C behavior, the plan is allowed up to 60 calendar days to review the case and respond. During this time, the plan may:
- Obtain legal counsel to determine the validity of the charge (fraud cases).
- Inform the member by certified mail that the PPG has requested transfer or termination and offer the member an opportunity to respond.
- Inform the provider relations & contracting specialist (formally provider network administrator) of the incident.
- Examine documentation to determine if transfer or termination is warranted with assistance from the regional medical director, Legal Department and Case Management Department, as appropriate.
For commercial lines of business, these behaviors can result in a transfer, but not in termination of coverage, except in the case of fraudulent activity.