Payment arrangements between Tufts Health Public Plans and participating providers may be direct or indirect. All providers in the Tufts Health Public Plans Direct network, with the exception of the providers listed in the table below, are paid on a Fee for Service basis. Some providers are paid through an Alternative Payment Model. An Alternative Payment Model is an agreement between Tufts Health Public Plans and a provider to arrange for covered services in a coordinated manner where the provider may share savings/risk with Tufts Health Public Plans. Providers paid under an Alternative Payment Models are paid on a Fee for Service basis and may have additional revenues based upon quality/efficiency performance.
Fee for Service
In this arrangement, the provider is paid a fixed fee by Tufts Health Public Plans for covered services that are provided to eligible members. Services are generally paid from an agreed-on schedule of payments. Fees may be in the form of actual charges less any discount negotiated by Tufts Health Public Plans, a fixed fee for each day of a hospitalization (known as a per diem) or based on a schedule of fees by service performed. The fee from Tufts Health Public Plans, along with any applicable payment from the member, such as copayment, coinsurance, and/or deductible, is the full payment to the provider for covered services.
In this arrangement, the provider shares risk with Tufts Health Public Plans. The risk is based on the provider delivering services above or below a budget mutually agreed to between Tufts Health Public Plans and the provider. This arrangement may include maximum thresholds for risk sharing based on the agreement between Tufts Health Public Plans and the provider.
In this arrangement, the provider shares in savings below a budget mutually agreed upon between Tufts Health Public Plans and the provider.
How to use this guide:
The following list identifies the contracted providers in the Tufts Health Public Plans Direct Network as of January 1, 2017 that have an Alternative Payment Model and a key identifying the specific type of payment arrangement based on the prior descriptions.
|Cambridge Health Alliance
|Steward Health Care Network
|Northeast Physician Hospital Organization
You can find out if your provider is part of one of these organizations by contacting us at 888-257-1985.
Key: 1. Fee for Service, 2. Shared Risk, 3. Shared Surplus