Gag Clauses

NM 8 provides:

The organization’s written agreements with participating providers do not include:
(a) Any clauses or language that could restrict participating providers from discussing matters relevant to consumers’ health care; nor
(b) A definition of “medical necessity” that emphasizes cost/resource issues above clinical effectiveness.

This is a mandatory standard, and all elements are primary.  It is the same for both Health Plan and Health Network accreditation programs.

This standard is quite straightforward, and yet is often missed, at least on desktop review.  It is the classic example of the “it is not enough that you do it right, you must have a policy and procedure that requires that you do it right” philosophy discussed in another blog on this site (http://integralhs.com/doing-right-not-enough-having-policy-do-it-right-required-too).

Very simply, submitting provider contracts that, in accord with the standard, do not include the two prohibited types of the language, is not enough.  You must also have a policy and procedure that prohibits the inclusion of such language in all provider contracts.  So, in your application, submit both a template agreement and the policy and procedure.