How Do I Determine if Our Entity is Considered a Risk-Bearing Organization?
A risk bearing organization is a professional medical corporation, other form of corporation controlled by physicians and surgeons, a medical partnership, a medical foundation exempt from licensure pursuant to subdivision (l) of Section 1206 of the Health and Safety Code, or another lawfully organized group of physicians that delivers, furnishes, or otherwise arranges for or provides health care services, but does not include an individual or a health care service plan, and that does all of the following:
- Contracts directly with a health care service plan or arranges for health care services for the health care service plan's enrollees.
- Receives compensation for those services on any capitated or fixed periodic payment basis.
- Is responsible for the processing and payment of claims made by providers for services rendered by those providers on behalf of a health care service plan that are covered under the capitation or fixed periodic payment made by the plan to the risk-bearing organization.
As a Risk-Bearing Organization, am I Required to File Quarterly and Annual Financial Reports Under SB 260? When are These Reports Due to the DMHC?
Quarterly financial survey reports are due to the department not more than forty-five (45) days after the close of each quarter of the fiscal year.
Annual financial reports are due to the DMHC not more than one hundred fifty (150) days after the close of the organization's fiscal year beginning on or after January 1, 2005, and not more than one hundred fifty (150) days after the close of each of the organization's subsequent fiscal years.
Are There Different Reporting Requirements for Risk-Bearing Organizations That Have Less Than 10,000 Covered Lives?
Organizations serving less than 10,000 covered lives under all risk arrangements are required to file a Compliance Statement addressing the following: (1) A statement as to what percentage of completed claims the organization has timely reimbursed, contested, or denied during the quarter; (2) A statement as to whether or not the organization has estimated and documented it's liability for IBNR claims; (3) A statement as to whether or not the organization has at all times during the quarter maintained positive TNE; and (4) A statement as to whether or not the organization has, at all times during the quarter, maintained a cash-to-claims ratio.
Regardless of the number of covered lives served under all risk arrangements, all risk bearing organizations are required to submit its annual financial survey report, not more than one hundred fifty (150) days after the close of the organization's fiscal year beginning on or after January 1, 2005, and not more than one hundred fifty (150) days after the close of each of the organization's subsequent fiscal years.
Are the Results of the Risk-Bearing Organizations' Financial Reports Available to the public?
Yes, within 120 days following each reporting period due date, the DMHC will make the following information available, on its website:
- A list of all risk-bearing organizations that have submitted substantially complete financial survey forms, if required, and whether the risk-bearing organization's submission reflects that the organization has met or not met each of the Grading Criteria.
- A list of all "non-compliant" organizations that failed to substantially comply with the reporting obligations.
- Comparative, aggregated data on all organizations, and information that enables consumers to assess an organization's relative financial viability.