Health Network 7.1

N-NM 17 - Participating Provider Suspension Mechanism for Consumer Safety

Submited by: Tom Goddard

The Basics

The standard is for the special situation of a provider whose conduct is so egregious as to give rise to a well-founded concern by your medical director that the provider is posing a threat to the well-being of your members. This is a very important consumer safety standard. Not only must your medical director be freed from the requirement of taking such a dispute through the normal, often slow, dispute resolution process, it places an affirmative requirement on him or her to handle such a situation in an expeditious manner.
The proper procedure, once the medical director concludes that the provider poses such a danger, is to suspend immediately the provider. Then, after the suspension, your organization should conduct an expedited investigation to make sure that the medical director's concerns were well-founded. Finally, the dispute resolution mechanism described in the previous standards must be made available to the suspended provider.

Management Tips

The requirements of this standard must be embodied in your credentialing plan or a policy and procedure that explicitly contemplates this circumstance. In addition, your medical director must be absolutely clear that he or she not only has this authority, but also an affirmative obligation to exercise this authority.

Accreditation Tips

Desktop Review
For the desktop review phase, you may submit the same documentation that you submit for the previous dispute resolution standards.  
Validation Review
Interviews
During the on-site review, this issue will come up in the reviewer's interview with the medical director. He or she must be prepared to answer this question, as it is almost a certainty to come up. This kind of emergency suspension procedure is fairly uncommon, so it would not be surprising if you had no documented examples. However, if you do, we recommend that you be prepared to produce one or more examples of such an emergency suspension for the reviewer's examination.

  • Health Network 7.1 / 03.26.2017

    N-NM 17 - Participating Provider Suspension Mechanism for Consumer Safety

    The standard is for the special situation of a provider whose conduct is so egregious as to give rise to a well-founded concern by your medical director that the provider is posing a threat to the well-being of your members. This is a very important consumer safety standard. Not only must your medical director be freed from the requirement of taking such a dispute through the normal, often slow, d...

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  • Health Network 7.1 / 03.26.2017

    N-NM 16 - Disputes Involving Administrative Matters

    This standard requires that your organization have a mechanism for disputes with providers in your network for largely administrator disputes. Essentially, any provider disputes that are not covered by the previous standard or by the health utilization management appeals standards are covered here.The mechanism that your organization is required to have for such disputes is simply the right to bri...

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  • Health Network 7.1 / 03.26.2017

    N-NM 15 - Disputes Concerning Professional Competence or Conduct

    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 p...

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