Posted by Credentialing
Credentialing is a requirement for participation in managed care programmers for doctors and office managers. Managed care organizations, including physician/hospital organizations (PHOs), preferred provider organizations (PPOs), and health maintenance organizations (HMOs), must be effective in finding and keeping skilled healthcare professionals who will offer their subscribers high-quality services. Credentialing is the term used to describe this selection and retention procedure. The process of reviewing and verifying the data of a healthcare provider interested in joining a managed care organization is known as Credentialing Services for Providers (MCO). Current professional licenses, Drug Enforcement Administration and Controlled Drug Substance Certificates, proof of schooling and post-graduate training, facility personnel privileges, and levels of liability insurance are all subject to review and verification.
Managed Care Credentialing
The main goals of Provider Credentialing Services are to make sure that candidates meet the minimal standards for a sought status and to assess if the credentials submitted with the application are adequate for the capabilities requested within the MCO. MCOs are rapidly being compelled by laws, rules, and accrediting criteria to complete the same level of credentialing that hospitals have long been expected to complete. An MCO can benefit from efficient credentialing, fair hearing and appeal procedures, and other factors. Risk management, accreditation, immunity from provider lawsuits under the Health Care Quality Improvement Act, and effective marketing to individuals looking to acquire health insurance policies, customers, and potential member providers are the very minimum of these benefits.
Risk Management
According to the principle of negligent credentialing, MCOs are accountable and can be held liable if they fail to properly execute a credentialing review and expose an injured subscriber to an untrained provider. They also assume the risk that subscribers may seek compensation when they suffer harm as a result of the negligence of a provider who is later determined to be unqualified. An MCO lowers its risk of exposure from a malpractice lawsuit brought by one of its members by exercising reasonable care in certifying and monitoring its providers.
Accreditation
Initially just accrediting HMOs, NCQA has since expanded its scope to include credentialing verification organizations (CVOs), Behavioral Health Services Texas, and physician organizations. All varieties of MCOs are accredited by JCAHO through its health care network accreditation program. JCAHO was originally a facility accreditation body. Additionally, PPOs and managed Behavioral Health Care Organizations are subject to a certain set of criteria.
Only businesses with a focus on conducting utilization evaluations are accredited by the AAHCC. They recently widened their scope to include accrediting MCOs. The QMC, the smallest certification body, also accredits independent practice associations and medical groups (IPAs). The importance of MCO accreditation is seen as an indicator to the public of the MCO devotion and commitment to the ideals of quality and continual improvement of services, which is why many MCOs place a high value on it. Some states demand accreditation of HMOs. Before signing up with an insurer, many health care consumers require or urge accreditation.
Immunity Under HCQIA
In order to be recognized as a “health care entity” under the Health Care Quality Improvement Act, an MCO must implement and carry out proper credentialing (HCQIA). The majority of HMOs fall under the definition of “health care entities,” and many PHOs and PPOs may as well if they offer medical services.
The HCQIA offers a wide range of immunities. It safeguards the members of the MCOs credentialing committee and any other MCO committee members taking part in activities connected to credentials, such as defending committee members in relation to credentials judgments. A physician who has been negatively impacted by a credentialing decision may not be able to bring legal claims, such as those for defamation and abuse of process, against an MCO thanks to the immunity. A healthcare organization is not shielded by the immunity from any civil rights complaints.
Positive Marketing
Managed care and credentialing undoubtedly have a close link. MCOs can thrive and expand with rigorous and efficient certification. Strong accreditations, immunity from physician lawsuits, a reduction in liability risk for malpractice and negligent credentialing, and effective marketing are just a few of the advantages it offers MCOs. Although efficient credentialing requires time and effort, the majority of MCOs believe the rewards far outweigh the expenses.