credentialing process
Lola2230
Chapter3-2.pptx
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© P.R. Kongstvedt
Chapter 3: The Provider Network
Learning Objectives
Understand the basic elements of payer-provider contracts
Understand service areas and access standards
Understand basic credentialing
Understand the basic types of contracted healthcare professionals
Understand the basic types of contracted healthcare facilities
Understand the basic types of contracted integrated provider health care delivery systems
Understand basic contracting for ancillary services
Understand basic network maintenance
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Payer and Provider Reasons for Contracting
[Put Table 3 – 1 here]
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Non-Negotiable Contracting Terms Required by Laws and Regulations
No Balance Billing and/or Hold Harmless
Compliance with Quality and Utilization Management programs
Maintenance of clinical standards, licensure, malpractice insurance, etc.
Maintenance and retention of records
Non-discrimination requirements
Compliance with privacy and security requirements
Acceptance of minimum number of patients from plan
Compliance with certain administrative requirements such as timely billing, access to records, addressing patient/member complaints, etc.
Compliance with Other Party Liability processes
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Contract Structure: Main Body vs. Appendices or Attachments
Elements that rarely change are in the main body; e.g. descriptions of provider services and the health plan’s obligations
Elements that often change are only referred to in the main body of the contract; actual terms are found in Appendices or Attachments
Allow certain terms to be modified without having to open the entire contract up for renegotiation
Actual payment terms and methods are almost always in an Appendix or an Attachment
Payment methods often separated from the specific dollar amounts
Payer may use one main contract body but use different payment Appendices for different products
Risk-sharing may also be separate even from payment terms for same reason
Any other non-payment terms that change from time to time
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Service Areas and Provider Access Standards
A service area is the specific geographic area in which a payer may sell certain products and services
Indemnity health insurers, administrators of self-funded plans, and TPAs are able to sell their products and services anywhere in the entire state in which they are licensed
HMOs are different
The service area for an HMO depends on the geographic area of its network
If the HMO cannot provide sufficient access to providers in an area, it cannot sell in that area either
Access standards usually determined by drive times or zip codes
Access standards differ by rural vs. urban, and by type of provider
States vary on PPO access standards, but usually do not have them
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The Professional Network
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| Examples of Non-Physician Professionals who may Contract with Payers | ||
| Clinical Nurse Practitioners (CNPs) | CNP Midwives | Respiratory therapists |
| Psychologist | Podiatrists | Optometrists |
| Clinical Social Worker | Physical therapists | Nutritionists |
| Licensed Professional Counselor | Chiropractors | Acupuncturists |
| Certified Alcohol and Drug Abuse Counselor | Dentists, orthodontists and oral surgeons | Audiologists |
| Psychiatric Nurse Practitioner or Nurse Psychotherapist | Occupational therapists | Home healthcare providers |
| Marital and Family Therapist | Other rehabilitation therapists |
Although focus here is on physicians, the network includes all contracted professionals who practice without the need for physician direction, and who bill for their services
Does not typically include professions working for facilities or in offices (e.g., nurses or other clinical personnel)
Adapted from Exhibit 3 – 1 in What They Are 4.
Hospital-Based Physicians (HBPs)
HBPs fall into one of five specialties:
Radiology
Anesthesiology
Pathology
Emergency Medicine
Hospitalist
Inpatients usually receive services from the first three, and often all five types
Member has no choice in who provides a hospital-based service
Membed not likely to know whether the HBP is a participating provider
HBPs often have monopoly-like negotiating power, and payers usually pressure the hospital to get them under contract with the payer
If HBP has not contracted with a plan, out-of-pocket cost can be high
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AKA “RAPs”
Physician Credentialing
Relatively standardized sets of criteria for credentialing and recredentialing physicians
The federal DataBank
National Practitioner Data Bank
Healthcare Integrity and Protection Data Bank
Credentials must be verified either by payer or by an accredited credentialing verification organization (CVO)
Until 2009, HMOs performed on-site office visits for primary care, OB/Gyn and high volume behavioral health providers; now done only if identified concern
Re-credentialing occurs every three years, based on a subset of the original credentialing data
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Common Types of Physician Contracting Situations
Individual physician
Traditional medical group
Group practice without walls (GPWW)
Independent practice association (IPA)
Faculty practice plans (FPP)
Specialty or Physician Practice Management Company (PPMC)
Management Services Organization (MSO)
Through a hospital or integrated delivery system (IDS) for physicians employed by the system
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Common Types of Hospital Contracting Situations
Community-based single acute care hospitals
Multi-hospital systems
All or none
Tied to flagship facility
Number of hospitals in multi-hospital systems is larger than number of free-standing acute care hospitals
For-profit national or regional chains
Specialized hospitals
Children’s hospitals
Other less common types such as eye and ear, women’s health
Physician-owned single specialty
Through an IDS
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Examples of Ambulatory Facilities in a Network
| Ambulatory Procedure Facilities | Other |
| Associated with a hospital | Birthing centers |
| Free-standing | Community health centers |
| Independent | Diagnostic imaging centers |
| Physician-owned | Subacute care or skilled nursing |
| Endoscopy centers | Hospice |
| Lithotripsy centers | Retail health clinics |
| Surgical recovery centers | Urgent care centers |
| Radiation oncology centers | Occupational health centers |
| Pain management centers | Women’s health centers |
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Examples of Ancillary Services (Some Overlap with Facilities)
Laboratory
Imaging, such as
Routine radiology (X-rays)
Nuclear imaging
Computed tomography (CT)
Magnetic resonance imaging (MRI),
Magnetic resonance angiography (MRA)
Positron emission tomography (PET) scans
Cardiac testing, such as
Electrocardiography
Plain and nuclear stress testing
Cardiac nuclear imaging and other invasive imaging
Echocardiography
Holter monitoring
Other diagnostic testing
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Cardiac rehabilitation
Non-cardiac rehabilitation
Physical therapy (PT)
Occupational therapy (OT)
Speech therapy
Other long-term therapeutic services
Examples of Diagnostic Ancillary Services
Examples of Therapeutic Ancillary Services*
* Not considered ancillary services if part of an inpatient stay
Ambulance and Medical Transportation are a category of their own
Credentialing of Facilities
Payers do not typically credential facilities
Rely on state licensure
Rely on accreditation agencies such as
Joint Commission (JCI)
The Healthcare Facilities Accreditation Program (HFAP)
Det Norske Veritas (DNV)
Accreditation Association for Ambulatory Health Care (AAAHC)
The American Association for Accreditation of Ambulatory Surgery Facilities Accreditation Program (AAAASF)
The Community Health Accreditation Program (CHAP)
The Accreditation Commission for Health Care (ACHC)
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Examples of Common IDSs and their Relationships with Independent and Employed Physicians
[Insert Table 3 – 3 here]
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