Your agreement with VSP requires you to comply with all applicable requirements under state and federal laws and regulations. According to the U.S. Department of Health and Human Services, applicable requirements include the following:

You are responsible for ensuring that you do not employ or contract with excluded individuals or entities, whether in a physician practice, a clinic, or in any capacity or setting in which Federal health care programs may reimburse for the items or services furnished by those employees or contractors. This responsibility requires screening all current and prospective employees and contractors against Office of Inspector General (OIG) List of Excluded Individuals and Entities. This online database can be accessed from OIG’s Exclusion Web site. If you employ or contract with an excluded individual or entity and Federal health care program payment is made for items or services that person or entity furnishes, whether directly or indirectly, you may be subject to a civil monetary penalty and/or an obligation to repay any amounts attributable to the services of the excluded individual or entity.

For more information, see OIG’s exclusion Web site available at http://oig.hhs.gov/fraud/exclusions.asp.

Keep Your Information Current with NPPES 

As a provider with an NPI, you are required to keep your information current with the National Plan and Provider Enumeration System (NPPES). To review or update your information, please visit https://nppes.com.hhs.gov/#/.  

VSP regularly monitors provider participation for Medicaid/Medicare. If a provider received payment from VSP during a time period when they were ineligible to participate in Medicaid/Medicare, VSP is required to recoup payment under Title XIX of the Social Security Act in accordance with 42, CFR, 438.608(d). This provision does not apply to any amount of recovery to be retained under False Claims Act cases or through other investigations.

MEDICARE ADVANTAGE CONTRACT PROVISIONS TO THE NETWORK DOCTOR AGREEMENT

The Centers for Medicare and Medicaid Services (hereinafter "CMS") requires that specific terms and conditions be incorporated into the Agreement between a Medicare Advantage Organization, a First Tier Downstream or Related Entity to comply with the Medicare laws, regulations, and CMS instructions, including; and

Except as provided herein, all other provisions of the Agreement between Vision Service Plan ("VSP") and Network Doctor not inconsistent herein shall remain in full force and effect.

Definitions:

Centers for Medicare and Medicaid Services ("CMS"): the agency within the Department of Health and Human Services that administers the Medicare program.

Downstream Entity: any party that enters into a written arrangement, acceptable to CMS, with persons or entities involved with the MA benefit, below the level of the arrangement between an MA organization (or applicant) and a first-tier entity. These written arrangements continue down to the level of the Network Provider of both health and administrative services.

First Tier Entity: any party that enters into a written arrangement, acceptable to CMS, with an MA organization or applicant to provide administrative services or health care services for a Medicare eligible individual under the MA program.

Medicare Advantage Plan ("MA"): an alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

Medicare Advantage Organization ("MA organization"): a public or private entity organized and licensed by a State as a risk-bearing entity (with the exception of provider-sponsored organizations receiving waivers) that is certified by CMS as meeting the MA contract requirements.

Provider: (1) any individual who is engaged in the delivery of health care services in a State and is licensed or certified by the State to engage in that activity in the State; and (2) any entity that is engaged in the delivery of health care services in a State and is licensed or certified to deliver those services if such licensing or certification is required by State law or regulation.

Related entity: any entity that is related to the MA organization by common ownership or control and (1) performs some of the MA organization's management functions under contract or delegation; (2) furnishes services to Medicare enrollees under an oral or written agreement; or (3) leases real property or sells materials to the MA organization at a cost of more than $2,500 during a contract period.

VSP and Network Doctor agree to the following:

1. Network Doctor agrees that Health and Human Services ("HHS"), the Comptroller General, or their designees have the right to audit, evaluate, and inspect any pertinent information for any particular contract period, including, but not limited to, any books, contracts, computer or other electronic systems (including medical records and documentation of the first tier, downstream, and entities related to CMS’ contract with a Medicare Advantage Organization, ("MA") through 10 years from the final date of the final contract period of the contract entered into between VSP and the MA organization or from the date of completion of any audit, whichever is later. [42 C.F.R. §§ 422.504(i)(2)(i) and (ii)]
   
   HHS, the Comptroller General, or their designees have the right to audit, evaluate, collect, and inspect any records under paragraph 1 of this contract provision directly from any first tier, downstream, or related entity. For records subject to review under paragraph 1, except in exceptional circumstances, CMS will provide notification to the MA organization that a direct request for information has been initiated. [42 C.F.R. §§422.504(i)(2)(ii) and (iii)]
2. Network Doctor will comply with the confidentiality and enrollee record accuracy requirements, including: (1) abiding by all Federal and State laws regarding confidentiality and disclosure of medical records, or other health and enrollment information, (2) ensuring that medical information is released only in accordance with applicable Federal or State law, or pursuant to court orders or subpoenas, (3) maintaining the records and information in an accurate and timely manner, and (4) ensuring timely access by enrollees to the records and information that pertain to them. [42 C.F.R. §§ 422.504(a)(13) and 422.118]
3. Enrollees will not be held liable for payment of any fees that are the legal obligation of VSP or the MA organization. [42 C.F.R. §§ 422.504(i)(3)(i) and 422.504(g)(1)(i)]
4. Network Doctor will not be eligible for payment and will be prohibited from pursuing payment from VSP enrollees after the expiration of the 60-day period specified in 42 C.F.R. § 422.222. The provider will hold financial liability for services, items, and drugs that are furnished, ordered or prescribed after the expiration of such 60-day expiration period. [42 C.F.R. §§ 422.504(g)(1)(iv), 422.504(i)(2)(v)]
5. For all enrollees eligible for both Medicare and Medicaid, enrollees will not be held liable for cost sharing when VSP or the State is responsible for paying such amounts. Providers will be informed of Medicare and Medicaid benefits and rules for enrollees eligible for Medicare and Medicaid. The Network Doctor may not impose cost-sharing that exceeds the amount of cost-sharing that would be permitted with respect to the individual under title XIX, Medicaid, if the individual were not enrolled in such a plan. Providers will: (1) accept VSP payment as payment in full, or (2) bill the appropriate State source. [42 C.F.R. §§ 422.504(i)(3)(i) and 422.504(g)(1)(i)]
6. Any services or other activity performed in accordance with a contract or written agreement by VSP or the Network Doctor are consistent and comply with the MA organization's contractual obligations. [42 C.F.R. § 422.504(i)(3)(iii)]
7. Contracts or other written agreements between VSP the MA organization and providers must contain a prompt payment provision, the terms of which are developed and agreed to by the contracting parties. VSP is obligated to pay contracted providers under the terms of the contract between MA Organization/VSP and Network Doctor. [42 C.F.R. §§ 422.520(b)(1) and (2)]
8. Network Doctor and any related entity, contractor or subcontractor will comply with all applicable Medicare laws, regulations, and CMS instructions. [42 C.F.R. §§ 422.504(i)(4)(v)]
9. If any of the MA Organization’s activities or responsibilities under its contract with CMS are delegated to VSP as a first tier, downstream, and related entity:

(i) The MA Organization reserves the right to revoke the delegation activities and reporting requirements or to specify other remedies in instances where CMS or the MA Organization determines that such parties have not performed satisfactorily.

(ii) The MA Organization will monitor the performance of the parties on an ongoing basis.

(iii) The credentials of medical professionals affiliated with the party or parties will be either reviewed by the MA Organization or the credentialing process will be reviewed and approved by the MA Organization and the MA Organization must audit the credentialing process on an ongoing basis.

(iv) If the MA organization delegates the selection of providers, the MA organization retains the right to approve, suspend, or terminate any such arrangement. [42 C.F.R. §§ 422.504(i)(4)(5)]

In the event that VSP, CMS, and/or MA determine that Network Doctor’s performance under this MA Contract provision is not satisfactory, VSP, CMS, and/or MA may revoke Network Doctor’s participation in the MA Program.

Except as provided in this Contract provision, all other provisions of the Agreement between Network Doctor and VSP not inconsistent with this Contract provision shall remain in full force and effect. This Contract provision shall remain in force as a separate but integral addition to the Agreement to ensure compliance with required CMS provisions, and shall continue concurrently with the term of the Agreement.

PERSONS ELIGIBLE FOR MEDICARE AND MEDICAID

Pursuant to the Affordable Care Act, the Centers for Medicare & Medicaid Services (CMS) implemented a national duals demonstration program for people dually eligible for Medicare and Medicaid to test new service delivery and payment models. The program may be called MMP or Duals.

The MMP/Duals are implemented through private health plans contracting with CMS and the applicable state Medicaid agency. Agreements with providers and other third parties who contract with health plans (directly or indirectly) must comply with applicable VSP/MMP contract requirements.

VSP and Network Doctor agree to comply with the following requirements:

To agree that cost sharing for Dual-Eligible Members is limited to the Medicaid cost sharing limits; and that for those dual-eligible Members the Network Doctor will accept VSP, and/or MMP payment as payment-in-full or will separately bill the appropriate state source for any amounts above the Medicaid cost sharing.