Ethical Challenges in Managed Care: A Casebook

By Karen Grandstrand Gervais; Reinhard Priester et al. | Go to book overview

9
Credentialing Standards and Quality Care

CASE STUDY

Nebraska Partners, an integrated health care system based in a large city in Nebraska, would like to expand its service area to a number of rural counties in order to participate in the Medicaid program. Federal Medicaid law requires that a managed care plan have an adequate provider network, defined to mean a primary care provider within thirty minutes or thirty miles and specialty providers within sixty minutes or sixty miles, of every enrollee. If Nebraska Partners cannot arrange for a complete network in these rural areas, it will not be able to obtain a Medicaid managed care contract.

In one rural town in particular, there is only one clinic made up of three physicians—two family practitioners and a surgeon. One of the family practitioners has a greater-than-average disciplinary history and an unusually high number of medical malpractice cases and was also recently denied coverage by his professional liability carrier. The other family practitioner is board certified only as a pathologist but has practiced and represents himself as a family practitioner. Finally, the surgeon never completed his surgery residency due to a family crisis and has never been board certified in surgery, but he has no disciplinary or medical malpractice history.

If this clinic were in the metropolitan area, Nebraska Partners would not contract with any of these providers because they would not meet the company's credentialing standards, and there are other providers who would. The credentialing standards require that every provider must have completed an accredited residency and be board certified in their stated area of practice. The standards also require that network providers have no significant disciplinary or medical malpractice history. If an applicant has one or two isolated incidents, the plan will solicit additional information and make a case-by-case determination. But in no case is a provider with a significant disciplinary history or history of

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