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Comprehensive Joint Replacement Program – Participation Criteria

Published on June 26, 2019

Comprehensive Joint Replacement Program – Participation Criteria

Statement of Policy

It is Pardee Hospitals’ (PH) mission to help people keep well in body, mind and spirit by providing quality health care services in a compassionate environment. PH fulfills its mission by ensuring that all of PH entities understand and follow federal requirements for the Comprehensive Care for Joint Replacement (CJR) program. Part of the CJR federal requirement is to maintain written policy for selecting participating providers for PH CJR program. This policy sets forth the PH’s selection criteria for provider eligibility for Collaborator agreements in the CJR model. PH requires all physicians, and other providers, who collaborate with PH to provide patient care under the CJR Model to provide care with the highest level of professional competence, and make patient care decisions on the basis of medical necessity and with the best interests of the patient in mind. This Policy applies to any physician, or provider, wishing to participate with PH in the CJR Model.

Procedure

I. CJR PHYSICIAN PARTICIPATION REQUIREMENTS

In order for a physician or provider to participate in the CJR Model with PH, through his or her respective group practice, respective group practice, the physician or provider must meet each of the following requirements:

  1. Maintain an unrestricted license to practice medicine in the state of North Carolina, which is not subject to any probationary terms or conditions;
  2. Maintain a current, unrestricted Drug Enforcement Administration (“DEA”) license which is valid in the State of North Carolina. Provisions may be made for an impaired practitioner who is in a recovery period;
  3. Be located (practice at a professional office or facility) within the geographic service area of PH that is close enough to fulfill the professional’s Medical Staff responsibilities and to provide timely and continuous care for patients at all PH hospitals;
  4. Maintain current, valid professional liability insurance coverage in a form and in amounts satisfactory to PH;
  5. Never have been convicted of Medicare, Medicaid, or other federal or state governmental or private third-party payer fraud or program abuse, nor have been required to pay civil monetary penalties for the same;
  6. Never have been, and not currently be, excluded or precluded from participation in Medicare, Medicaid, or other federal or state governmental health care program;
  7. Never had Medical Staff appointment, clinical privileges, or status as a participating provide denied, revoked, or terminated by any health care facility or health plan for reasons related to clinical competence or professional conduct;
  8. Never resigned a Medical Staff appointment or relinquished privileges during a Medical Staff investigation or in exchange for not conducting such an investigation;
  9. Never been convicted of, or entered a plea of guilty or no contest to, any felony; or to any misdemeanor relating to controlled substances, illegal drugs, insurance or health care fraud or abuse, or violence; 
  10. Be board certified in the physician or provider’s primary area of practice at PH, or an affiliated facility, by the American Board of Medical Specialties, the American Osteopathic Association, as applicable;
  11. Maintain board certification and, to the extent required by the applicable specialty/subspecialty board, satisfy recertification requirements;
  12. Meet and continue to meet the criteria for PH’s Medical Staff membership set forth in PH’s Medical Staff Bylaws;
  13. Maintain at all times clinical privileges at PH to practice commensurate with the services to be performed under the CJR Model;
  14. Be a participating provider in the Medicare Fee for Service Program;

Current Pardee Hospital participating CJR Collaborators:

  • Werner C. Brooks, M.D.
  • John M. Hicks, M.D.
  • Edward G. Lilly, M.D.
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