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The provider contract that Dr. Nick Mancini has with the Utopia Health Plan includes a clause that requires Utopia to reimburse Dr. Mancini on a fee-for-service (FFS) basis until 100 Utopia members have selected him as their primary care provider (PCP). At that time, Utopia will begin reimbursing him under a capitated arrangement. This clause in Dr. Mancini's provider contract is known as: 

The provider contract that Dr. Laura Cartier has with the Sailboat health plan includes a section known as the recitals. Dr. Cartier's contract includes the following statements: 

Medicaid beneficiaries pose a challenge for health plans attempting to establish Medicaid provider networks. Compared to membership in commercial health plans, Medicaid enrollees typically 

One reimbursement method that health plans can use for hospitals is the ambulatory payment classifications (APCs) method. APCs bear a resemblance to the diagnosis-related groups (DRGs) method of reimbursement. However, when comparing APCs and DRGs, one of the primary differences between the two methods is that only the APC method  

Dr. Sylvia Cimer and Dr. Andrew Donne are obstetrician/gynecologists who participate in the same

provider network. Dr. Comer treats a large number of high-risk patients, whereas Dr. Donne’s

patients are generally healthy and rarely present complications. As a result, Dr. Comer typically

uses medical resources at a much higher rate than does Dr. Donne. In order to equitably compare

Dr. Comer’s performance with Dr. Donne’s performance, the health plan modified its evaluation to

account for differences in the providers’ patient populations and treatment protocols. The health

plan modified Dr. Comer’s and Dr. Donne’s performance data by means of