The National Committee for Quality Assurance (NCQA) mandates that health plans convene regularly to make decisions about the credentialing of their network practitioners. In these committee meetings, external experts assess whether providers qualify to remain in the network. While these meetings are essential for compliance, many health plans find it challenging to conduct them efficiently and effectively.
We’re here to provide you with a comprehensive guide on how these meetings are conducted and offer valuable tips to maximize their efficiency. Additionally, we have a complimentary reference guide available for you, so make sure to download yours!
Credentialing Committee Meeting 101
Who participates in credentialing committee meetings?
Committee participants are healthcare providers and experts from outside of the health plan. It’s critical that Committee members are not affiliated with the plan so that they can maintain professional objectivity; however, the composition of the Committee might change depending on what kind of providers are being reviewed at a given meeting.
When does the credentialing committee meet?
The Committee should meet on a regular basis, and in most cases meetings are scheduled monthly. NCQA regulations mandate that committee meetings take place either in person or via video conferencing – which means emails aren’t sufficient for conducting a full committee meeting.
What happens at a committee meeting?
At the meeting, participants review providers’ credentials. Based on information presented, members decide whether to approve or deny a practitioner’s privileges within the network. NCQA regulations require the Committee to document the reasoning behind all decisions.
Typically, one person takes the lead in presenting provider information. Committee members have the option to ask follow-up questions regarding the provider’s license status and other important details. In cases where the Committee is unable to reach a decision on a practitioner, they will table the matter for later review. It is important to note that this outcome is not ideal as it unnecessarily increases the Committee’s future workload.
Best Practices for Efficient Credentialing Committee Meetings
Successfully running a committee meeting requires managing a substantial amount of information and presenting it in an easily understandable format. Proper preparation is crucial for achieving desired outcomes. We suggest implementing the following best practices:
- Strategic Categorization: During preparation, it’s beneficial to categorize practitioners into segments such as “clean files”, “expired licenses”, or “malpractice claims”. This aids in structured discussion and decision-making.
- Keep it Concise: Prepare succinct summaries of each provider. While comprehensive data is essential, it’s equally important to avoid overwhelming committee members with superfluous details.
- Provide Data: Always be equipped with supporting data, especially pertaining to providers’ licensing statuses and other pivotal agreements.
- Peer Review: Prior to the meeting, have the prepared summaries reviewed by a peer for clarity and completeness.
- Preparation: Rehearse reading summaries in advance. This ensures a confident presentation and helps in refining the content.
How andros Streamlines Credentialing Committee Meeting Preparation & Management
At andros, we collaborate with health plans to ensure effective preparation and execution of committee meetings. Our streamlined process highlights the significance of maintaining well-organized information.
First, we start by going through the regular process of credentialing practitioner files. After this step is completed, we assign levels to each file. This approach streamlines the preparation process and enables the Committee to prioritize files that require careful consideration.
Illustrative Case:
Company A
Level 1 – Clean:
Files categorized as Clean have no credentialing issues. These files typically bypass committee review.
Level 2 – Leveling Review:
Includes recent malpractice cases. To be considered a Level 2 case, it must involve a settlement of $1,000,000 or more. Initially, Level 2 cases are reviewed by Company A’s Chief Medical Officer (CMO). If the CMO does not approve the credential, it will be escalated to the Committee for a final decision.
Level 3 – Committee:
Files with any action, flag, sanction, or alert that has occurred within the last ten years or three years (based on the credential event) are assigned a Level 3 designation. Level 3 cases are reviewed by the Committee on a monthly basis. The report will include information about the event that triggered the Level 3 designation. While Level 3 reports hold the most importance for the Committee, Company A also receives reports on other levels. Level 1 reports are sent twice a week, and Level 2 reports are sent once every two weeks.
Through our systematic approach, we provide companies like ‘Company A’ with an organized methodology for committee meetings, aiding in informed decision-making and ensuring thorough post-meeting documentation.
In conclusion, the efficiency and effectiveness of credentialing committee meetings are paramount. By leveraging best practices and methodologies like those offered by andros, healthcare plans can ensure compliance and maintain the highest standards of care.
As you delve deeper into the nuances of file categorization and the intricacies of committee meetings, having a concise and comprehensive reference at your fingertips can be invaluable. We’ve created a detailed “Reference Guide on File Categorization and Committee Meeting Process” for you to keep on-hand. This guide breaks down each step and level, emphasizing its importance and role in maintaining network integrity. Don’t miss out on this essential tool – click below to download your copy and streamline your understanding of the process.
