As you probably already know, NCQA requires health plans to meet periodically to make credentialing decisions about network practitioners. During this process, known as a committee meeting, outside experts will determine whether providers should continue to be credentialed for the network. These regular meetings are critical for health plans’ compliance, but many plans struggle when it comes to running committee meetings in an efficient and effective manner.
We’re here to give you the rundown on the basics of how these meetings are run, as well as a few pointers on making them as efficient as possible. We’ve also got a complimentary template for you, so be sure to grab yours!
Committee Meeting Basics
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.
Usually, one person takes point for presenting provider information. Committee members may choose to ask follow-up questions about the provider’s license status and other critical information. If the Committee cannot reach a decision about a practitioner one way or the other, they will be tabled and reviewed later. This isn’t an ideal outcome because it adds to the Committee’s future workload unnecessarily.
Tips for Smooth Committee Meeting
Running a committee meeting involves keeping track of a huge amount of information and presenting it in an accessible format. Preparation is critical for success. We recommend implementing these best practices:
- Sort practitioners into broad categories during your meeting preparation. Some general categories to consider are clean files, expired licenses, DEA, and files with malpractice claims. You might choose to create further subdivisions on malpractice files.
- Keep summaries of each practitioner succinct so that you can proceed at an efficient pace. Committee members can always ask follow-up questions as necessary, but there’s no need to over-burden them with information upfront. In many cases, basic information is sufficient for the Committee to make a decision. The person who will be running the meeting should prepare short summaries of every provider ahead of time.
- Come to the committee meeting prepared with supporting information. It’s particularly important to know providers’ licensing status and whether the provider is still in an agreed order. Follow-up questions from committee members often touches on this issue, so you should make sure that you can look up this information quickly.
- Before the meeting, ask someone to read over the prepared summaries. Ask them if they would be able to reach a quick decision based on the information provided. If there is confusion, find out why and try to write a summary that offers greater clarity.
- Practice reading a few summaries ahead of time so that you’re comfortable in front of the doctors. Reading your work out loud can also help you to eliminate unnecessary wordiness.
How andros Streamlines Committee Meeting Preparation & Management
andros works with health plans to prepare for committee meetings and then run them. Our process demonstrates the importance of keeping information well-organized.
First, we go through the normal process of credentialing practitioner files. Once this is completed, we assign levels to every file. This makes the preparation process efficient and allows the Committee to focus on the files that are in most need of deliberation.
We work with networks to determine criteria for the levels. Let’s take for example our work with one client, who we’ll call Company A.
Company A has three basic levels. First, there’s Level 1, which is sub-divided into Clean and Exception categories. Files in the Clean categories have no credentialing issues. We designate files as Level 1 Exceptions if they have a minor issue. One example of this might be an expired license in a state where Company A does not contract. Some files with malpractice claims can also be classified as Level 1 Exceptions. Generally, we do this if the malpractice case was more than 10 years ago for initial credentialing and more than three years ago for recredentialing. Level 1 files do not need to be reviewed by the Committee.
Level 2 includes files with malpractice cases that are more recent. To qualify as a Level 2 case, the malpractice case must also include a settlement of $1,000,000 or more. As a first step, Level 2 cases are reviewed by Company A’s Chief Medical Officer. If the CMO does not initially approve the credential, then it will be escalated to the Committee where the outcome will be decided.
The Level 3 designation is assigned to files with any action, flag, sanction, or alert that has occurred within the last ten years or three years (based on the credential event). Level 3 cases are the ones that go to the Committee every month. The report will include information about the event that triggered the Level 3 designation. Although Level 3 reports are most relevant for purposes of Committee, Company A also receives reports on other levels. We send Level 1 reports twice a week, and Level 2 reports once every two weeks.
Thanks to the leveling system, we can help Company A make a quick and effective decision during the committee meeting, and we take on the task of preparing the information for presentation. After Committee, we also prepare a report summarizing what action was taken.
