Health Care Quality Improvement Act and Clinically Integrated Provider Networks
Clinically integrated networks present unique credentialing issues that are normally not present in hospital or facility credentialing. These unique issues stem from the very nature of integrated networks which require providers to comply with evidence-based protocols, individualized care plans, quality metrics, efficiency standards, and other system standards.
In order to assure compliance with these standards, integrated networks need to assert much more control over the clinical practices of its provider members than has historically been exercised in the hospital setting. Credentialing and recredentialing processes need to be put in place to assure that providers practice in conformance with evidence-based practice protocols, coordinate care with other network providers, and otherwise work well within the system.
Integrated networks face a number of choices when determining how to structure their credentialing and recredentialing processes. A threshold decision is whether the credentialing process should be structured to take advantage of the immunities that are available under the Health Care Quality Improvement Act (“HCQIA”).
Qualifying under the HCQIA has some benefits but also carries some burdens. In order to qualify for HCQIA immunities, the organization must implement a formal credentialing, hearing, and appeal process in order to qualify for immunities.
A CIN must also register with the HRSA and is required to make reports to the Practitioner Databank if adverse peer review determinations are made. The CIN receives a Data Bank Identification Number and can be penalized for not reporting adverse determinations. The reporting requirement is an issue that provider networks may wish to avoid. The obligation to report has the practical effect of making peer review actions much more controversial and prone to litigation because a database report is a serious negative mark on a physician’s record.
On the other hand, the immunities offered by the HCQIA can be extremely valuable to a clinically integrated network. One of the immunities that is available under the HCQIA is from the treble damage provisions under federal antitrust laws. This immunity cannot be discounted; particularly with provider networks that make more aggressive credentialing decisions based on achievement of quality and cost issues and infirmity with system protocols.
If a choice is made to secure the HCQIA immunities, a comprehensive credentialing, peer review and fair hearing process is required as is use of the Practitioner Databank. Furthermore, in order to qualify, adverse actions only be taken in furtherance of quality healthcare, after a reasonable effort to develop the facts, with adequate notice and hearing to the affected practitioner. The Act and interpreting case law have created rather detailed requirements for notice and hearing. The end result is that extensive procedural processes must be in place and consistently followed by the organization. This of course adds another layer of complexity and cost to the organization. At the same time, it greatly decreases the organization’s potential liability exposure which under certain circumstances could greatly exceed the cost of complying with HCQIA requirements.