Managed Care Credentialing
The fundamental purpose of Provider Credentialing Services is to ensure that applicants meet the minimum requirements for a requested status and to determine whether the application credentials are appropriate for the requested privileges within the MCO. Laws, regulations, and accreditation standards increasingly require MCOs to carry out the same level of credentialing that hospitals have long been required to carry out. Effective credentialing, and fair hearing and appeal processes all provide several advantages for an MCO. These advantages, at a minimum, include: risk management, accreditation, immunity from providers lawsuits under the Health Care Quality Improvement Act and positive marketing to those seeking to purchase health care policies, consumers, and potential member providers.
Immunity Under HCQIA
Another reason for an MCO to implement and perform proper credentialing is to qualify as a “health care entity” under the Health Care Quality Improvement Act (HCQIA). Most HMOs qualify as “health care entities” and many PHOs and PPOs may also meet this definition if they provide health care services.
The immunity conferred by the HCQIA is broad. It protects the MCOs credentialing committee members, and any other MCO committee members engaging in credentialing-related activities, including covering committee members with respect to credentialing decisions. The immunity can help to avoid suits against an MCO by a physician adversely affected by a credentialing decision, including suits for defamation and abuse of process. The immunity does not protect a health care entity from any civil rights claims.
Cities: Dallas, Southfield, Dublin
Counties: Collin County, Oakland County, Franklin County
Zip Codes: 75252, 48075, 43017