Physiatry Practice Management Resources

On the other hand, decredentialing a physician opens an increasingly large can of worms. We are all familiar with the multitude of factors which have led to the creation of highly adversarial relationship between physicians and MCOs. When you layer on top of that the adverse financial impact to physicians who are decredentialed, it's no wonder decredentialing decisions are being fought with increasing frequency and fervor.

The first major stumbling block likely to be encountered by an MCO is the result of an historical accident. Years ago, many physicians were enrolled under significantly looser credentialing standards (a license and malpractice insurance were enough) either because MCOs were attempting to fill panels or because they were apt to rely on the credentialing mechanisms of hospitals. While standards have been substantially tightened since then, they are also inconsistent with standards that were applied on the front-end selection. Such inconsistent application can leave a decredentialed physician feeling angry and bewildered and muttering words like "call my lawyer."

MCOs also take a lot of heat for decredentialing tied to utilization or financial performance. It is the goal of every MCO is to be staffed with quality, efficient, low-utilization physicians. But a constant, consistent pattern of physician deselection for overutilization and economic performance is also a potential lightning rod for litigation.

Last, but not least, patients now have a keen interest in decisions by an MCO to deselect their doctors.

The bottom line is that credentialing and decredentialing by MCOs of individual physicians is subject to attack by many parties on many grounds. What MCOs must do in response is make certain that their credentialing process is as airtight as possible.

Some thoughts on how to accomplish this:

MCOs must do their own credentialing, or contract the responsibility out to competent third parties. They cannot rely on the credentialing of hospitals and others.

Credentialing criteria must go beyond individual physician qualifications and take into consideration the full range of beneficiaries' needs. For example, an MCO will often be responsible for arranging for the total health needs of enrollees rather than just inpatient hospital services. Thus, criteria such as configuration of office space, accessibility to the office, and coverage for the physician's practice must be considered. These criteria should be reviewed on occasion.

Credentialing criteria should applied as consistently as possible, not only from physician to physician but upon recredentialing or decredentialing as well. It is possible that a physician might be enrolled on the front end who subsequently might not meet applicable criteria. "Blemishes" should be duly noted along with the reason for acceptance of the application. For example, the physical layout of the physician's office might not have met preferred standards, etc., yet his enrollment might have been made, given the needs of the particular community. The "blemish" should be noted along with the compelling reason(s) to accept the application in light thereof.

MCOs should consider credentialing and recredentialing on a "physician-blind basis," where the identity of an applicant is not revealed when the initial criteria are applied.

The credentialing process should be completely objective. Hence, physician-members of the credentialing committee who are also participating members of the MCO should refrain from any substantive discussion or vote on any applicant within their specialty area of practice who are candidates for deselection (to avoid claims of antitrust).

Each physician must be afforded proper due process upon deselection. Due process can also be used to document application of the criteria. Due process includes notice of the reason for deselection and an opportunity to meet with the governing body (the entire body and not just one or two members) to discuss the matter before a final decision is rendered.

Criteria and due process are equally critical. One without the other is insufficient. All the due process in the world cannot protect against criteria which are wrongfully applied (e.g., race, disability and the like). Similarly, a decision to deselect for the right reasons will be subject to attack if the process is inadequate.

The credentialing process must be in writing and formally adopted by the MCO's board. Any modifications should similarly be adopted and in writing.

Every physician member should have a copy of the process which should be made a part of, by attachment to, his/her physician contract. The process should be not be inconsistent with any term or provision of the physician's contract.