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
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.

  • 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.

  • 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...

  • 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...