Medicare (Title XVIII of the Social Security Act)
Payments to HMOs and Competitive Medical Plans

Payments to HMOs and Competitive Medical Plans265

The HMO must provide meaningful procedures for hearing and resolving grievances between the organization and its enrolled members.266  The organization must have arrangements for an ongoing quality assurance program for health care services it provides to its enrolled members, which stresses health outcomes267 and provides review by health care professionals of the process followed in the provision of such health care services.268  Each contract will provide that the Secretary has the right to inspect or otherwise evaluate the quality, appropriateness and timeliness of services performed under the contract269 and shall have the right to audit and inspect any books and records of the eligible organization that pertain to services performed under the contract. 270

Each risk-sharing contract with an HMO will provide that the organization will maintain a written agreement with a utilization and quality control peer review organization.271  Each contract will provide that the organization may not operate a physician incentive plan that places a physician at substantial financial risk for services not provided by the physician unless the organization conducts periodic surveys of individuals currently and formerly enrolled to determine the degree of access of such individuals to services provided by the organization and satisfaction with the quality of such services.272