EXAMPLES OF WHAT HMO’S MIGHT LOOK FOR TO RECRUIT OR CONTRACT WITH PHYSICIANS AND HOSPITALS – Class 6

What Credentialing a Provider Means to a Physician Executive:

  • Credentialing a provider is a process of review to approve a provider who applies to participate in a health plan
  • Specific criteria and prerequisites are applied in determining initial and ongoing participation in the health plan

In recruiting physicians, HMOs might look for:

  • Physicians who agree to follow the principles of managed care
  • If its a PCP to serve as a “Gatekeeper”
  • Work with shared risk
  • Board eligible or board certified
  • Affiliated with contracted hospitals
  • Provide after hours care – does the physician refer to emergency room or able to take care of patients after hours, triage
  • Credentialing criteria
  • Services performed in office, such as every lab test sent out. Generally, more physician can do in the office – the more cost efficient
  • Understand how to work with capitation, especially to handle the business side of what capitation implies, such as:
  1. Having agreements with their own specialists
  2. Settle claims
  3. Good public relations
  4. Avoid worse excesses, such as blame HMO when things don’t work out

In recruiting hospitals, medical directors or provider relations of HMO’s might look at hospitals:

  • Willing to negotiate rates based on per diem as an all inclusive figure
  • Allow utilization management function to operate
  • Agree not to bill members even if HMO denies service
  • Joint Commission Accreditation Hospital Organization (“JCAHO”) accredited, licensing in order, meet standards in terms of their own accreditation

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