Provider Credentialing Services

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2. Revenue CycleManagement PayerServices Electronic HealthRecords Credentialing For physiciansandofficeadministrators,credentialingisanecessaryiniquity in order to partake in managed care plans. Managed care organizations such as health maintenance organizations (HMOs), preferred provider organizations (PPOs) and physician/hospital organizations (PHOs) must successfully select and retain qualified health care providers who will provide quality services to their subscribers. This process of selection and retention is known ascredentialing. Provider Credentialing Services is the process of review and verification of the information of a health care provider who is interested in participating with a managed care organization (MCO). Review and verification includes: current professional license(s), current Drug Enforcement Administration andControlled Drug Substance Certificates, verification of education, post-graduate training, facility staff privileges and levels of liabilityinsurance. Managed CareCredentialing The fundamental purpose of Provider Credentialing Services is to ensure that applicants meet the minimum requirements for a requested status and to determinewhethertheapplicationcredentialsareappropriatefortherequested privileges within the MCO. Laws, regulations, and accreditation standards increasingly require MCOs to carry out the same level of credentialing that hospitals have long been required to carry out. Effective credentialing, and fair hearing and appeal processes all provide several advantages for an MCO. These advantages, at a minimum, include: risk management, accreditation, immunity from providers lawsuits under the Health Care Quality Improvement Act and positive marketing to those seeking to purchase health care policies, consumers, andpotential member providers. RiskManagement Under the theory of negligent credentialing, MCOs are responsible and can be heldliableforexposinganinjuredsubscribertoanunqualifiedproviderbyfailingto conduct a proper credentialing review. They also undertake the risk that subscribers can look to collect damages when the subscriber is injured due to the malpracticeof aproviderdeemedlatertobeunqualified. AnMCOthatexercises

3. reasonablecareincredentialingandmonitoringitsprovidersreducesitsriskof liability of a malpractice suit by one of itsmembers. Accreditation In its inception, NCQA used to limit its accreditation to HMOs, but has recently expanded to accredit Credentialing Verification Organizations (CVOs), Behavioral Health Services Texas and Physician Organizations. JCAHO, which started out as a facility accreditation organization, accredits all types of MCOs through its health care network accreditation program. They also have a specific set of standards for PPOs and managed Behavioral Health Care Organizations. The AAHCC only accredits organizations that specialize in carrying out utilization reviews. They have recently broadened their focus to accredit MCOs. Finally, the smallest accreditationgroup,theQMCaccreditsmedicalgroupsandIndependentPractice Associations (IPAs). MCO accreditation is important to many MCOs because the value of accreditation is looked upon as an indication to the public of the MCO devotion and commitment to the principles of quality and continuous improvement of services. Some states require HMOs to be accredited. Many health care purchasers require or encourage accreditation before they will sign on with aninsurer. Immunity UnderHCQIA Another reason for an MCO to implement and perform proper credentialing is to qualify as a "health care entity" under the Health Care Quality Improvement Act (HCQIA). Most HMOs qualify as "health care entities" and many PHOs andPPOs may also meet this definition if they provide health careservices. The immunity conferred by the HCQIA is broad. It protects the MCOscredentialing committee members, and any other MCO committee members engaging in credentialing-related activities, including covering committee members with respect to credentialing decisions. The immunity can help to avoid suits against an MCO by a physician adversely affected by a credentialing decision, including suits for defamation and abuse of process. The immunity does not protect a healthcareentityfromanycivilrights claims. PositiveMarketing Credentialing and managed care definitely share a strong relationship. With effective and thorough credentialing, MCOs are able to prosper and grow. It also provides several benefits to MCOs, which include a decrease in liability risk for malpractice and negligent credentialing, strong accreditations, immunities from physician lawsuits, and positive marketing. While effective credentialingtakes time andeffort, mostMCOsfeelthatitsbenefitsclearlyoutweighthecosts.

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