TECHNIQUES USED BY PHYSICIAN EXECUTIVES TO GET CONTRACTED PHYSICIANS TO FOLLOW RULES – Class 6

Some Typical Procedures Medical Directors Might Use if a Participating Physician Does Not Follow Rules Involving Quality:

  • Calling physician and trying to correct problem
  • Peer review
  • Corrective action plan might be implemented with respect to that physician’s performance – such as requiring physician to take Continuing Medical education (“CME”) course in a particular subject
  • Ultimately de-credentialing

If a physician does not follow the rules involving quality, there are typically procedures that come into play such as having theses type of cases reviewed in peer review, or a corrective action plan might be implemented with respect to that physician’s performance such as requiring physician to take a Continuing Medical education (“CME”) course in a particular subject, or calling physician and trying to correct the problem, or freezing physician’s membership until they show they have corrected the defect and ultimately decredentialing the provider. Decredentialing would usually require peer review and review by credentialing committee and if there is decredentialing having the entity comply with its reporting requirements with the National Data Bank.

Most problems that HMO’s have from certain specialties not knowing the HMO rules come form : (1) Physician’s in IPA’s because they are less likely to know the HMO’s rules, and (2) Consultant’s at tertiary level because they frequently know nothing of the HMO’s rules.

Some medical directors do not use the word “discipline” when talking about physicians not following the HMO rules. These medical directors tend to believe physicians are their partners and do not want to be adversaries, that they want to work together to reduce health care costs. Some HMO’s might use report cards on physicians and based on that work to reduce costs, change physician’s mindset, to work with physicians, share information, and monitor the physicians.

Medical directors might not be directly responsible for recruiting physicians but might come into recruit for special services or at the tertiary level.

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