Contracted Provider Dismissal Policy

SUD Specialty Group -- CA; Mental Health Specialty Group, P.A.; Mental Health Specialty Group NJ, PC; and Mental Health Specialty Group KS, P.A. (collectively, the "Group") contracts with Path CCM, Inc. d/b/a Rula Health ("Rula") for management and administrative support services. This policy applies to the Group and Rula. 

Policy Statement

Rula is committed to the delivery of high-quality care to patients and ensuring compliance with all relevant laws and regulations. In the event that a clinical provider is found to have violated these quality expectations and compliance standards, the organization has a responsibility to investigate, intervene, and take action, ranging from educational consultation to dismissal from the network and termination of the provider’s contract with Rula.  

This policy applies only to 1099 contractor providers working with the Group.  Further, this policy sets out the procedures to be followed when dismissing contracted providers for compliance, quality, credentialing, and/or clinical care issues, in addition to outlining the steps taken to manage the patient experience after provider dismissal.

Applicability

This policy applies to all contracted providers at Rula involved in patient care.

Definitions

Dismissal: the act of terminating a provider’s contract with Rula so that they can no longer provide services to clients through Rula’s platform

Policy

1. Expectations

1. Providers must hold an unrestricted active license in good standing to practice and maintain malpractice insurance at all times (at minimum $1,000,000/$3,000,000).  
   1. Any lapses in licensure and insurance will result in dismissal from the Group.
   2. Any license that is shown as "Delinquent" due to failure to renew in a timely manner is subject to dismissal. If the provider’s state board supplies information that the process of updating their primary source is delayed, and provider shows proof of renewal completed, the provider is informed they will be held in a paused status and unable to treat clients until primary source verifies license is current and unrestricted.
2. Providers must comply with all applicable federal and state regulations of respective clinical licensure, as well as internal Group policies and procedures. 
3. Providers are expected to meet Rula’s designated quality standards.  Quality issues may be identified through regular quality audits, peer review, patient complaints, and other means of monitoring clinical care.  All providers will have access to their individual quality data to self-monitor clinical performance upon request.  Rula will notify providers prior to any updates if/when changes are made to quality expectations and metrics.
4. Providers are expected to abide by and follow the Rula’s Compliance Plan (ex. completing HIPAA training) and Code of Conduct. Violation may be grounds for dismissal or termination of a contractual relationship with the Group.
5. Providers may be immediately dismissed from the network if any of the above are violated, including but not limited to not submitting renewed Certificate of Insurance, having a lapsed/inactive license, lack of engagement with quality or response to quality outreaches, and/or repeated violations of the Code of Conduct. 

B. Reporting

1. Any concerns related to compliance, quality, credentialing, or clinical care should be reported to clinical quality. This includes, but is not limited to, concerns related to patient safety, quality of care issues, patient experience, professionalism, and failure to follow established protocols and maintain all requirements for independent practice.

C. Investigation

1. Clinical Quality Leadership or designee will conduct a thorough investigation of any concerns reported using a standardized template and attempt to engage the provider in a discussion regarding the reported concerns. The Compliance Officer will guide the investigation in relation to concerns that are primarily compliance-related (for example, false billing allegations). 
2. The investigation may include interviewing patients/providers, reviewing medical records, data analysis, reviewing complaints and grievances, and/or consulting with external experts as necessary.
3. While the investigation is taking place, a provider may be “paused” from receiving new patients depending on the severity of the reported issue.
4. Findings will be classified by severity in accordance with the provider quality management escalation pathways, as appropriate.
5. After the investigation is complete, recommendations will be made to the Quality and Patient Safety Governance Committee for further action and can include: 
   1. No action: No or insufficient evidence of concern
   2. Continued monitoring
   3. Email outreach from Clinical Quality Specialists with supportive resources. 
   4. 1:1 Quality Consultation can be recommended or required, with or without an accompanying quality success plan. 
   5. Pausing the provider to new patient referrals can be temporary or indefinite
      1. An indefinite pause to new patient referrals indicates that there are no identified patient safety concerns or serious violations of Rula quality standards that occurred. In these instances, the provider may be non-responsive to outreaches, but able to maintain an appropriate level of quality performance, including patient experience of care with the provider.  
      2. The provider will be allowed to continue care with their current caseload of clients, and will not receive new patient referrals from Rula. 
      3. This option allows providers to safely continue care with their current caseload of clients, and thus supporting continuity of care.  
   6. Pausing the provider to payments for services provided: This action is generally taken when a provider is potentially over utilizing services or engaging in unauthorized care with their client(s). 
   7. Dismissal from the network
6. If the investigation determines that the provider has violated any quality, compliance, or clinical care standards and dismissal is not recommended, the provider will be given written notice of the violation, actions taken, and given an opportunity to correct the issue.  A Quality Specialist will be assigned to provide education and support to mitigate the likelihood of recurrence.
7. If the provider fails to correct the issue within the designated timeline, does not participate in creating a quality success plan or engage with quality, or if the violation is severe, the provider’s contract with Rula may be terminated.

D. Termination of the Provider Contract/Dismissal from the network

1. If the recommended action is dismissal, Quality will notify the provider via email with a follow-up text (SMS) message. 
   1. Providers will be discontinued from patient care immediately after notification. 
   2. A representative from Clinical Leadership or designee will follow the internal dismissal workflow to ensure that the provider is removed from the network and future correspondence. 
   3. All steps involved in processing a provider’s departure from Rula will be expedited in the case of a dismissal decision. 
2. In certain circumstances, upon termination the provider may have the opportunity to appeal the dismissal decision. 
   1. Circumstances where an appeal right does not exists:
      1. An appeal is not granted in situations where there is a material breach of contract and no external reporting occurs. 
   2. Circumstances where an appeal right does exist:
      1. Reporting to the provider’s licensure and/or certification board(s) may be required per regulatory standards and laws. 
3. Depending on the circumstances (i.e. severity of the issue), the Group will decide at the time of the dismissal, if the provider may rejoin Rula in the future, no sooner than one year from the dismissal date. Providers will be ineligible to rejoin Rula in the future if they are dismissed for the following reasons:
   1. If a provider was dismissed, offered the opportunity to appeal, and did not appeal within the required timeframe, they will not be allowed to reapply to be a provider in the network. 
   2. If a provider was dismissed to any of the following reasons, they will not be eligible to reapply for participation in the network:
      1. Investigation found evidence of potential or actual patient harm occurred, or failure to address patient safety. 
      2. Investigation found that the provider had engaged in significant ethical violations (such as sexual/romantic boundary violations with a patient, financial exploitation of a patient, etc.)
      3. Investigation resulted in dismissal and reporting to licensure board
      4. Dismissals initiated based on serious billing concerns
      5. Evidence of persistently not meeting quality standards including untimely or missing documentation, non-utilization of measurement informed care, poor therapeutic alliance and/or patient satisfaction scores.  
      6. Previous non-responsiveness to quality or other Rula staff outreaches.  

E. Management of Patient Experience

1. In the event that a provider’s contract is terminated, the organization will take steps to ensure that patient care is not compromised and abandonment does not occur. This will include offering patients reassignment to another clinician, providing additional support and resources as needed, and ensuring that patients are informed of the situation as soon as possible and prior to the next scheduled appointment to minimize any disruption in the continuity of their care.
2. The patient(s) will be notified that their provider is no longer available through Rula and patient rematching is coordinated with Clinical Quality, Care Coordination, and Support Teams.

F. Appeal Process

1. In cases where there is evidence that patient harm occurred, or Rula is obligated, per regulatory requirements, to report the provider to their licensure and/or certification boards, providers will be given the right to appeal their termination from the network. The right to appeal does not apply when the provider was dismissed from the network for a material breach of their contract with Rula. 
2. The provider must submit a written appeal by emailing quality@rula.com within 30 days of their dismissal date. 
3. The written appeal must include the reasons for the appeal and any relevant documentation or evidence.
4. Members of the Quality and Patient Safety Governance Committee - Appeal Review Subcommittee will review the appeal and additional evidence provided by the provider.
5. The Appeal Review Subcommittee may request a meeting with the provider to discuss the appeal and gather additional information.
6. The Appeal Review Subcommittee will make a decision on the appeal and notify the provider in writing within 30 days of receiving the appeal.
7. Members of the Appeal Review Subcommittee will not have been previously involved in the provider dismissal decision to ensure a fair and equitable appeal process. 

Attachments: 

A: None.