Managed Care Credentialing
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.