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Why it's important, and why outsourcing may be the way to go
As a healthcare organization/plan (HCO/P) selects or develops a network of providers to serve the customer, it focuses first of all on ensuring that a sufficient number and proper geographic distribution of practitioners exist. It may, however, put less effort into looking at providers' eligibility standards-not a good idea, because practitioner credentialing provides an excellent opportunity (and a new challenge) for plans to do the following:
incorporate quality providers;
set national credentialing eligibility requirements;
include outcome measurement indices into the profiling of those practitioners;
monitor provider adherence to ethical/professional standards; and
make more cost-effective credentialing decisions, with the aid of a credentials verification organization (CVO).
Seeking appropriate accreditation is one of the costs of doing business in the behavioral healthcare field, and credentialing is a significant component in the HCO/P's achieving accreditation. Employers, state and regional organizations, various coalitions and the other purchasers of healthcare services place great importance on accreditation of healthcare organizations by the National Committee on Quality Assurance (NCQA), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Committee on Accreditation for Services to Families & Children (COA), the Commission on Accreditation of Rehabilitation Facilities (CARF) or the Utilization Review Accreditation Commission/American Association of Healthcare Accreditation (URAC/AAHC), and an HCO/P's credentialing policy plays a significant role. For instance, 20% of the total points needed to qualify as an NCQA-accredited organization is attributed to credentialing procedures.
HCO/Ps must also be aware of liability and the role that a good credentialing system can play in safeguarding the health plan. Increasingly, recipients of healthcare services question the decisions made in a managed care environment. Sometimes this dissatisfaction results in litigation against hospitals or against HMOs, over what is perceived as faulty credentialing.
By restricting coverage to services provided by therapists on a provider roster, these organizations may deny or severely limit a beneficiary's freedom to choose a provider. This makes the HCO/P vulnerable to potential liability since it "selected" the provider. Therefore, the selection and credentialing of providers deserves special attention (or "due diligence") to ensure that the HCO/P roster of preferred providers contains providers capable of delivering quality healthcare.
Certification Criteria Differ
The HCO/P should recognize that the selection criteria...