Last month, we advised physicians not to allow themselves to be decredentialed without putting up a fight. This month, we advise managed care organizations that, well, physicians are going to fight decredentialing -- and as a result, MCOs should approach this process very carefully.
There are many forces at work resulting in increased scrutiny of MCOs when credentialing and decredentialing physicians:
Credentialing by MCOs is driven not so much by statutory or regulatory requirements, but by accreditation and liability concerns. Accreditation is important (a) to demonstrate to consumers and purchasers who rely on managed care services that the organization has been impartially reviewed and found to meet nationally recognized standards and best practices, and (b) to improve quality by identifying areas for enhancement. Insulation from liability has become increasingly important as courts, in recent years, have applied numerous legal theories of liability to MCOs, making them responsible for the acts of their physicians.
Although many MCOs are beginning to do an admirable job of tight, first-time physician enrollment, accreditation and liability concerns dictate that recredentialing be performed consistently and periodically throughout the term of a physician's contract or upon its renewal.
A major issue with decredentialing is that, years ago, many physicians were enrolled under looser credentialing standards, either because MCOs were attempting to fill panels or because they were apt to rely on the credentialing mechanisms of hospitals. Thus, while standards may have tightened or become more specific to the requirements of the MCO, they're inconsistent with standards that were applied during initial selection. This can leave a decredentialed physician feeling angry and bewildered, and muttering words like "antitrust."
Another major issue is that decredentialing is often tied to utilization or financial performance. The goal of every MCO is to be staffed with quality, efficient, low-utilization doctors. But a consistent pattern of physician deselection for overutilization is also potential for litigation -- unless physicians are also being deselected for other, documented, justifiable reasons.
Physicians have become increasingly dependent upon MCO participation, and some have little choice but to fight deselection -- warranted or not. Deselection from any network can mean the loss of a significant revenue base.
Finally, patients now have a keen interest in an MCO's decision to deselect their doctors.
The bottom line is that credentialing and decredentialing by MCOs of physicians is subject to attack by many parties on many grounds. What MCOs must do is make certain that their credentialing process is airtight and bulletproof.
So what steps should an MCO take?
Criteria and due process are equally critical. One without the other is insufficient. All the due process in the world cannot protect against criteria that are wrongfully applied. Similarly, a decision to deselect for the right reasons will be subject to attack if the process is inadequate.
Finally, the process must be in writing and formally adopted by the MCO's board. Physicians should have a copy of the process, which should be a part of their contracts.
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Managed Care / Legal Forum
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