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Archive for the ‘Credentialing’ Category

HCQIA and Clinically Integrated Provider Networks

Tuesday, July 7th, 2015

Health Care Quality Improvement Act and Clinically Integrated Provider Networks 

Clinical Integration HCQIAClinically integrated networks present unique credentialing issues that are normally not present in hospital or facility credentialing.  These unique issues stem from the very nature of integrated networks which require providers to comply with evidence-based protocols, individualized care plans, quality metrics, efficiency standards, and other system standards.

In order to assure compliance with these standards, integrated networks need to assert much more control over the clinical practices of its provider members than has historically been exercised in the hospital setting.  Credentialing and recredentialing processes need to be put in place to assure that providers practice in conformance with evidence-based practice protocols, coordinate care with other network providers, and otherwise work well within the system.

Integrated networks face a number of choices when determining how to structure their credentialing and recredentialing processes.  A threshold decision is whether the credentialing process should be structured to take advantage of the immunities that are available under the Health Care Quality Improvement Act (“HCQIA”).

Qualifying under the HCQIA has some benefits but also carries some burdens.  In order to qualify for HCQIA immunities, the organization must implement a formal credentialing, hearing, and appeal process in order to qualify for immunities.

A CIN must also register with the HRSA and is required to make reports to the Practitioner Databank if adverse peer review determinations are made.  The CIN receives a Data Bank Identification Number and can be penalized for not reporting adverse determinations.  The reporting requirement is an issue that provider networks may wish to avoid.  The obligation to report has the practical effect of making peer review actions much more controversial and prone to litigation because a database report is a serious negative mark on a physician’s record.

On the other hand, the immunities offered by the HCQIA can be extremely valuable to a clinically integrated network.  One of the immunities that is available under the HCQIA is from the treble damage provisions under federal antitrust laws.  This immunity cannot be discounted; particularly with provider networks that make more aggressive credentialing decisions based on achievement of quality and cost issues and infirmity with system protocols.

If a choice is made to secure the HCQIA immunities, a comprehensive credentialing, peer review and fair hearing process is required as is use of the Practitioner Databank.  Furthermore, in order to qualify, adverse actions only be taken in furtherance of quality healthcare, after a reasonable effort to develop the facts, with adequate notice and hearing to the affected practitioner.  The Act and interpreting case law have created rather detailed requirements for notice and hearing.  The end result is that extensive procedural processes must be in place and consistently followed by the organization.  This of course adds another layer of complexity and cost to the organization.  At the same time, it greatly decreases the organization’s potential liability exposure which under certain circumstances could greatly exceed the cost of complying with HCQIA requirements.

New Paper On Credentialing of Telemedicine Providers

Monday, April 21st, 2014

I have published a new “Blue Paper” covering credentialing of telemedicine providers.  This issues has emerged over the past several years are telemedicine is growing in usage.  The article covers the relatively new CMS regulations regarding the credentialing process and provides some useful tips to providers who are actively engaging in telemedicine.

You can find the new Blue Paper at the following ling:  Telemedicine Credentialing Article

Distant Site Telemedicine Credentialing Conditions

Thursday, April 17th, 2014

Reliance On Distant-Site Hospital or Telemedicine Entity Credentialing

Reliance On Distant Site for Telemedicine Credentialing

The 2011 CMS regulation modified conditions of the participation for hospitals and critical access hospitals to permit the hospital to have its medical staff rely on the distant-site hospital credentialing decisions when making recommendations on privileges for individual physicians and practitioners providing telemedicine services. However, this process is only permitted when a number of conditions are met:

  • The telemedicine services must be provided pursuant to a written agreement with the Medicare participating distant-site hospital or qualifying distant-site telemedicine entity.
  • The agreement must specify that it is the responsibility of the governing body of the distant-site hospital to meet the existing requirements for credentialing of providers who are providing telemedicine service.
  • The distant-site hospital providing the telemedicine services must be another Medicare participating hospital or a “telemedicine entity.”
  • The distant-site physician or other practitioner must have been privileged at the distant-site hospital providing telemedicine services and the distant-site hospital must provide a current list of telemedicine physicians and practitioners who are privileged there and their current privileges at the distant-site hospital or entity to the hospital or CAH.
  • The distance site practitioner must hold a license that is recognized by the state in which the hospital whose patients are receiving telemedicine services is located
  • The hospital must have evidence of an internal review of the distant-site physician’s or practitioner’s performance under telemedicine privileges and must send this information to the distance site hospital for use in the distant-site hospital’s periodic appraisal of the distant-site physician’s provision of telemedicine services.
  • Information sent for use in the periodic appraisal must at a minimum have included all adverse events that resulted or could have resulted from telemedicine services provided by the distance site provider to the originating hospital’s patients and all complaints received by the originating hospital with respect to the distance site physician or practitioner.

John H. Fisher

Health Care Counsel
Ruder Ware, L.L.S.C.
500 First Street, Suite 8000
P.O. Box 8050
Wausau, WI 54402-8050

Tel 715.845.4336
Fax 715.845.2718

Ruder Ware is a member of Meritas Law Firms Worldwide

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