RS 40:2202

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RS 40:2202

§2202. Definitions

As used in this Part, the following definitions shall apply:

(1)"Alternative rates of payment" shall mean the rate at which or sum for which the provider agrees to perform specified services. The rate shall be negotiated between purchaser and provider and shall be in effect for a fixed term. It may, but need not, include a discount from the provider's customary fee.

(2)"Governmental body" means any department, commission, council, board, office, bureau, committee, institution, agency, government, corporation, or establishment of the executive branch of this state.

(3)"Group purchaser" shall mean an organization or entity which contracts with providers for the purpose of establishing a preferred provider organization. "Group purchaser" may include:

(a)Entities which contract for the benefit of their insured, employees, or members such as insurers, self-funded organizations, Taft-Hartley trusts, or employers who establish or participate in self-funded trusts or programs.

(b)Entities which serve as brokers for the formation of such contracts, including health care financiers, third party administrators, providers, or other intermediaries.

(4)"Hospital" shall mean any institution, place, building, or agency, public or private, whether for profit or not, including a facility subject to the jurisdiction of a hospital service district, devoted primarily to the maintenance and operation of facilities for ten or more individuals for the diagnosis, treatment, or care of persons admitted for overnight stay or longer who are suffering from illness, injury, infirmity, deformity, or other physical condition for which obstetrical, medical, or surgical services would be available and appropriate. It may also include nursing homes as defined by and regulated under the provisions of R.S. 40:2009.1 through 2009.12.

(5)(a) "Preferred provider organization (P.P.O.)" shall mean a contractual agreement or agreements between a provider or providers and a group purchaser or purchasers to provide for alternative rates of payment specified in advance for a defined period of time in which:

(i)The provider agrees to accept these alternative rates of payment offered by group purchasers to their members whenever a member chooses to use its services.

(ii)There is a tangible benefit to the provider in offering such alternative rates of payment to the group purchaser.

(b)The contractual agreement or agreements may also include incentives which encourage the insured employee or member to utilize the participating providers.

(c)No licensed provider, other than a hospital, who agrees to the terms and conditions of the preferred provider contract shall be denied the right to become a preferred provider to offer health services within the limits of his license.

(d)However, nothing in this Part shall be construed to require any hospital to grant any provider or class of providers medical staff membership.

(e)Preferred provider contracts should include, but not be limited to, the following components:

(i)Participating in a resource monitoring component to ensure quality control both for patient care and cost effectiveness.

(ii)Procedures to encourage prompt payment for services rendered.

(6)"Provider" shall mean one or more entities which offer health care services and shall include but not be limited to hospitals, individuals, or groups of physicians, individuals or groups of psychologists, nurse midwives, ambulance service companies, and other health care entities. Any health care entity which is specifically covered by a group purchaser's insurance policy, employee benefits, self-funded organization or Taft-Hartley trust benefits or plan shall be construed to be a "provider" for purposes of consideration under this Part.

(7)"Tangible benefit" shall mean but not be limited to:

(a)Any reasonable expectation of a demonstrable increase in or maintenance of usage of the provider's services.

(b)Contractual provisions requiring quality control of patient care and participation in resource monitoring procedures; or

(c)Any reasonable expectation of prompt payment for services rendered.

Added by Acts 1984, No. 374, §1, eff. July 6, 1984; Acts 1995, No. 967, §1, eff. Sept. 1, 1995; Acts 1999, No. 1274, §1, eff. July 12, 1999; Acts 2018, No. 206, §4.

NOTE: See Acts 1999, No. 1274, §2.