QUALITY ASSURANCE

Provider Credentialing Procedures
HMOs must have systems to ensure the minimum competency of the health care providers in their networks. These are called credentialing procedures. The HMO must check physicians’ credentials before listing them in its provider directory or other materials given to members (11 NCAC 20.0401 et. seq.). For example, the HMO must check the following information on physicians:

• Personal information;
  
• Practice information, including the non-work hours that the provider can be contacted (call coverage);
  
• Education and training history;
  
• Current provider license, registration or certification. States where the provider has previously been licensed, certified or registered should be listed;
  
• Drug Enforcement Agency registration and any prescribing restrictions;
  
• Specialty board certification, professional and hospital affiliation;
  
• The amount of professional liability coverage and the provider’s malpractice history;
  
• Any disciplinary actions by medical organizations and/or regulatory agencies;
  
• Any felony or misdemeanor convictions;
  
• The type of affiliation requested; and
  
• A statement signed and dated by the applicant attesting to the truthfulness and completeness of the information submitted.
  

HMOs must also obtain information on health care facilities, including accreditation status from the Joint Commission on Accreditation of Health Care Organizations, state licensure information, Medicaid and Medicare certification and evidence of current malpractice insurance.

HMOs must verify all information included in the provider’s application for credentials and must reverify the provider’s credentials not less than once every three years. The HMO is responsible for ensuring that these rules are followed, even if it subcontracts the credentialing process to another organization.

Disciplining Providers Who Provide Inappropriate Care
HMOs must have a mechanism to reduce, suspend or terminate providers from participating in the network if the HMO believes the physician is providing poor quality of care or the physician drops malpractice coverage (11 NCAC 20.0411). In addition, HMOs, like other health care institutions, must report to the Board of Medical Examiners any time it revokes, suspends, or limits a physician’s practice privileges or when a physician decides to stop participating in the plan (NCGS 90-14.13). This law was established to ensure that the Board of Medical Examiners is alerted to any potential provider competence issues.

Internal Quality Assurance Systems
HMOs must also have an internal quality assurance system to ensure the overall performance of the HMO and the quality of health care services provided to its members (11 NCAC 20.0501 et. seq.). The HMO must employ a variety of tools to assess the quality of health care services provided in different types of treatment settings. The HMO must also ensure the quality of its internal administrative and utilization review operations. In addition, the system must include procedures to investigate and take corrective action in response to patient complaints about the providers or HMO decisions. Any HMO that delegates the quality management activities to another organization must ensure that the other organization follows state laws.

RETURN TO HOMEPAGE