Develop best-fit managed care credentialing criteria
CRC Daily opens this week’s coverage of the ever-evolving practitioner vetting landscape with a closer look at criteria for managed care credentialing.
Accreditation and regulatory standards for managed care credentialing establish a minimum standard that health plans use to identify appropriately qualified individuals and organizations to participate in their networks and to provide quality care to their members.
Before a health plan can begin to credential, it must define the scope of its network. There are many different types of healthcare providers that a health plan may credential to offer services to its members. If a managed care organization (MCO) is specialty specific (e.g., a dental network), then the scope of providers will be much more limited than for an MCO that provides primary care and specialty services.
In its policies, a health plan must describe its criteria for credentialing and recredentialing practitioners within its scope. Such criteria include licensure, Drug Enforcement Agency (and/or state Controlled Dangerous Substance) certification, malpractice insurance, education, training, and board certification. Accreditors do not require specific criteria or define how the health plan must apply its criteria; the organization makes those decisions. For example, what does the health plan want to require to ensure a quality network for its members? Is board certification mandated or optional? What makes sense, based on geographical differences, for malpractice insurance limits or claims history?
A health plan that has a large rural member base may have different requirements when it comes to board certification or malpractice insurance limits, as it may be more difficult to attract and retain practitioners in those areas. At a minimum, health plans must require current licensure in the state in which the practitioner will treat members.
The credentialing processes that a health plan follows should be described in sufficient detail to ensure compliance with accrediting and regulatory requirements. While most health plans will perform a review process, URAC specifically requires that the credentialing policies describe the process by which the health plan reviews credentialing information for completeness, accuracy, and conflicting information. A health plan can meet this standard by conducting inter-rater reliability or peer audits, using checklists, or running reports through its credentialing database.
Source: Credentialing for Managed Care: Compliant Processes for Health Plans and Delegated Entities