1. Cost Containment & Physician Incentives.
* Among the methods you use to control costs, do you, directly or indirectly, provide any kind of financial and/or job security incentives (negative or positive) to any of your physicians to limit diagnostic tests and referrals to specialists?
* Describe in detail your cost control methods as they affect your physicians and other medical care providers.

2. Physician Credentials.
* Do you check the credentials of your physicians?
* Who does the checking for you, and what methods are used?
* Does the check include a history of malpractice lawsuits?
* Can a physician work with your patients before his/her credentials check is complete?

3. Medical Necessity.
* How do you define “medically necessary”?
* If there is some disagreement as to what is “medically necessary” for one of your patients, who in your organization makes the final decision?

4. Appeal Procedures.
* If a specific medical treatment is turned down, is there an appeal procedure within your organization?
* How long, on the average, does it take to give the patient the final answer?
* Must the patient initiate the appeal?

5. Choice of Physicians.
* If a patient in your Plan wants to switch to another physician in your Plan, can s/he do so?
* How can a patient consult with a physician who is NOT in your Plan?

6. Revenue Breakdown.
What percentage of your HMO revenue goes for:

* Patient Care? _________%
* Administration and Overhead? __________%
* Payments to Stockholders? ___________%

7. Prescription Drugs.
Most HMOs have formularies, which are lists of the prescription drugs approved for use by their physicians. Physicians are often pressured to prescribe only the drugs on the formulary, and in some cases pharmacies are given bonuses to switch a prescription to the cheapest drug available.

* Do you offer bonuses to pharmacies to switch prescriptions?
* Are physicians limited to prescribing only the drugs on your formulary?
* Formulary drugs can be of three types. Please indicate the percentage of each type in your formulary:
o Standard brand-name drugs: ___________% of your formulary.
o Generic drugs, which are claimed to be chemically equivalent to the brand names but are usually less expensive: ___________% of your formulary.
o So-called “therapeutic alternatives” which are chemically different from brand-name or generic drugs, but which are supposed to have similar therapeutic effect: __________% of your formulary.

Sometimes, for a variety of reasons, the generic and “therapeutic alternative” drugs are less medically effective, and may therefore be dangerous to the patient.
* If a physician in your Plan determines that a given generic or “therapeutic alternative” drug is not the best drug for a given patient, is the physician free to prescribe the appropriate brand-name drug, and will your Plan pay for it?

8. Access to Specialists.
* What must a patient do to see a specialist in your Plan?
* On average, how long does a patient wait to see a specialist?

9. Patient Satisfaction.
* Do you regularly conduct patient satisfaction surveys?
* Do you survey patients who are leaving or have left your HMO because of dissatisfaction with the treatment provided?
* Do you give bonuses to individual physicians and other care providers based on the satisfaction of the patients they have treated?

10. Emergency Care.
* If one of your members thinks that s/he has a medical emergency—and if a prudent lay person would consider that this medical situation is a true emergency—would your member be able to go to the nearest emergency room for treatment, even if that ER is not a part of your Plan?
* In such a case, would you require authorization from your staff before treatment could be provided?
* If you have different rules for “emergency care” and “urgent care,” how do you define the difference between the two? Give examples of each.