Health Network 7.1

N-NM 15 - Disputes Concerning Professional Competence or Conduct

Submited by: Tom Goddard

The Basics

This standard outlines the minimum requirements for a particular kind of provider dispute resolution process: those disputes that involve issues related to the provider's professional competence or conduct, or impact the provider's status within the provider network. For such disputes, your organization must provide the following:

  • A first-level appeal, to be held by a panel of no fewer than three people, one of whom must be a clinical peer of the disputing provider who is not otherwise involved in network management;
  • A right to a second-level appeal, also before a panel of no fewer than three people, one of whom must be a clinical peer of the disputing provider who is not otherwise involved in network management.

Management Tips

For most organizations, the easiest way to address this standard is to empower a senior clinician to convene first-level appeals and second-level appeals panels on an as-needed basis. This helps to ensure that the panels contain the required clinical peer, a requirement that is sometimes harder to meet if you're gonna station is using standing committees, such as credentialing committee's, as one of the panels.
It is important to note that these appeals process is need not be made available to all participating providers who are terminated from the network. If a provider no longer meets minimum requirements for dissipating in the network, such as possessing a valid of an active license or maintaining hospital admission privileges, he/she is not entitled to the appeals mechanisms required by the standard.

Accreditation Tips

Desktop Review
Begin by submitting the provider dispute resolution policies and procedures. And addition, if you have examples of providers requesting dispute resolution within the period under review for this accreditation, submit blinded samples of the provider's request for dispute resolution, blinded correspondence with such providers, and blinded meeting minutes of panels considering such disputes. If, on the other hand, if your organization has not had disputes within the scope of the standard, submit an attestation to that effect. Make sure the attestation is on organization letterhead and signed by a senior executive.
Validation Review
Document Review

Have ready for the reviewer a list of all provider disputes within the scope of the standard. The reviewer will want to look at complete files for those disputes, or at least some of them. If your organization still has not received any requests for dispute resolution within the scope of this standard, have prepared a fresh attestation to that effect.
Interviews
We will conduct interviews of the medical director and other senior network management staff in order to determine their level of understanding of the processes for dispute resolution.

  • Independent Review Organization: Internal Review 5.0 / 11.28.2017

    IR-INT 5 - Internal Review: Additional Reviewer Qualifications for Appeals

    IROs must have more rigorous qualifications for reviewers handling appeals. In addition to the requirements outlined in the previous standards, reviewers handling appeals must be board certified, if an MD, DO, or DPM.

    READ FULL POST
  • Independent Review Organization: Internal Review 5.0 / 11.28.2017

    IR-INT 4 - Reviewer Qualifications

    Under this standard, the IRO must establish qualifications for its reviewers. At a minimum, those requirements must include the following:Current, non-restricted license or certificate as required under U.S. law for clinical practice;At least five years FTE experience with direct clinical care;Must be a clinical peer (i.e., "a physician or other health professional who holds an unrestricted licens...

    READ FULL POST
  • Independent Review Organization: Internal Review 5.0 / 11.28.2017

    IR-INT 3 - Credential Status Changes

    This standard requires that the IRO have and implement policies and procedures that both require the IRO's staff members to notify the IRO in the event there is an adverse change in the status of the staffer's license or certification (including board certification) andprovide a procedure to implement a corrective action plan in the event of such an adverse change.In other words, if a member of th...

    READ FULL POST
Top