What is Preferred Care of the Virginias?
Preferred Care of the Virginias is a not-for-profit Physician Hospital Organization (PHO) which offers to its members, participation in formulating the growth and the development of managed care products and programs through a combined physician/hospital relationship.
Preferred Care of the Virginias has been formed as a not-for-profit, non-stock membership corporation. Ownership is structured with 50% shared equally among physician members (Class A Members), and the other 50% owned equally by Bluefield Regional Medical Center and Princeton Community Hospital (Class B Members).
What is the Governance Structure of Preferred Care of the Virginias?
Governance of the PHO will be conducted by a Board of Directors consisting of sixteen (16) Class A Members (physicians only) and four (4) Class B Members (hospitals only). The Bylaws require a Board of Directors composition consisting of eight (8) physicians who are “Generalists” (family practice, pediatrics, internal medicine without a subspecialty, emergency room and OB-GYN physicians), eight (8) physicians who are “Specialists”, and two (2) representatives from each Hospital. The Class A directors elected by the physicians will consist of a minimum of six (6) of the eight (8) “Generalists” from family practice, pediatrics or internal medicine without a subspecialty physicians and three (e) surgical specialists, three (3) medical specialists and two (2) hospital based (anesthesiology, pathology, or radiology) physicians.
What are the Membership Dues for a member?
Membership dues have been set at $1250.00 per year for Specialists, $750.00 per year for Generalists, and $375.00 per year for Allied Health Professionals. Bluefield Regional Medical Center and Princeton Community Hospital combined will contribute an amount equal to the total physicians’ dues paid. The Board of Directors will review the need for dues assessment annually.
What are the eligibility requirements for a provider to apply for membership in the PHO?
Any provider that wishes to become a member of the PHO may request an application. Each completed application will be credentialed in accordance with the PHO’s Credentialing Program and Bylaws. Consideration for membership may also be based upon the needs requirements of the PHO. Submission of a completed application does not constitute automatic participation with the PHO. Upon approval of the application and receipt of the provider’s dues and contract participation, the membership will be activated.
In addition to the initial operations, how will the ongoing operations of the PHO be funded?
The initial operations of the PHO will be funded by the membership fees of its members. Subsequent operations will be funded via fee income for services provided by the PHO for contracts with insurance companies, third party claim administrators, and administrative fees, etc. It is anticipated that the PHO will be totally self sufficient and supported in full from revenue generated from its services and programs.
Does membership in Preferred Care of the Virginias limit the provider in any way from either continuing to participate in existing contracts with payors, or with future payors?
No. As a member of the PHO nothing will preclude you from contracting with any payor you desire outside of a PHO contract. As a participating member of the PHO you agree to participate as a provider in contracts negotiated and approved by the PHO, in accordance with the guidelines established in the Provider Participation Agreement.
What will generally be the claim processing procedures of the PHO?
Generally, all PHO claims will be filed by the Provider directly with the payor. Payment of the claim, less any appropriate copays or deductibles will be made directly to the Provider and will not be made through the PHO. All Purchaser contracts will have a provision requiring certain standards in ‘turn around time’ on payment of a claim, accuracy, and information required to be sent to the Provider with the payment. The PHO will assist the Provider in any way possible to assure complete accuracy and promptness of payment of a claim. The PHO will also intervene on behalf of the Provider on any disputed or delayed claims with a Purchaser, when requested by the Provider.
Will the PHO be receiving payment of claims directly from any Purchaser, thereby being responsible for payment of claim to a Provider?
No. All fee for service contracts with the PHO will require direct payment of a claim to the Provider.
How is the 3% Administrative Fee implemented?
As required in the Participating Provider Agreement, The PHO will use its best efforts to negotiate payment arrangements with all payors where the PHO provides administrative services (Section 3.4). To the extent the PHO is not able to obtain payments by the payors for the PHO services, or if the payment is inadequate for the services provided, the Agreement makes an allowance for the PHO to charge a member and the hospital an Administrative Fee for those services not to exceed 3% of the amount otherwise payable to the provider. The maximum 3% is applicable only to the payment amount to the provider or the hospital and is not applicable to any copays or deductibles collected from a patient. Generally, the PHO will require payment for its services by the Payor and will make every attempt to avoid implementation of the 3% Administrative Fee. It is also recommended that any payor who refuses to pay for the PHO services receive a higher fee schedule from the PHO to offset any administrative charge required by the PHO.
If a member has an existing contract with a Purchaser who also contracts with the PHO, will the member be required to terminate the existing contract with the Purchaser?
No. A provider who is a member shall use his/her best efforts not to enter into new or renewal terms of existing contracts with a payor who also has a contract with the PHO for services. However, nothing contained in the Agreement is intended to prevent the provider from negotiating and entering into agreements directly with payors.
Please refer to Section V of the Agreement for complete information. Generally, however, termination of membership shall not relieve either the PHO or the provider of obligations imposed with respect to services furnished prior to the termination, the obligations of the PHO and provider with respect to members hospitalized at the time of termination, or with respect to continuing obligations to members as provided in Section 5.6 of the Agreement. The provider will have the obligation to continue services to a member after termination, except in certain instances, such as, but not limited to, failure to maintain licensure in West Virginia, until the obligations to a Payor Contract have been fulfilled. The PHO, however, will make every effort to locate a replacement PHO provider to provide services to a member within a maximum of ninety (90) days after termination.
