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.

  • IRO Core 3.0 / 12.28.2017

    IRO CORE 38 - Consumer Safety Mechanism

    One of the most important of the URAC standards is this one, which requires that the organization have processes to respond quickly to urgent situations that threaten consumers' well-being.Even though the standard speaks of "a mechanism", the reality is that it requires a system of mechanisms dealing with the full array of urgent situations that are likely to confront the applicant. You can see th...

  • IRO Core 3.0 / 12.28.2017

    IRO CORE 33 - Financial Incentive Policy

    This standard says, essentially, that if the organization has a system by which people are provided financial incentives that are based directly on consumer utilization of healthcare services, there must be mechanisms in place to make sure that these incentives don't end up compromising consumer care. This policy includes capitation of providers. Not all URAC reviewers over the years have interp...

  • IRO Core 3.0 / 12.28.2017

    IRO CORE 32 - Senior Clinical Staff Responsibilities

    The senior clinician whose qualifications are set forth in Core 31 must, according to this standard, provide guidance and be responsible for all of the clinical aspects of the organization's program being accredited. In addition, the senior clinician must have periodic consultation with individuals in the field or licensed to deliver healthcare services without supervision, i.e. practitioners. F...