credentialing credentialingcommittee Feb 24, 2023
Managed Healthcare Resources Credentialing Committees

Peers, Practitioners, and Providers

We often read or hear about a practitioner being accused of misconduct or adverse events that occurred at a hospital.  You may have even witnessed an occurrence yourself.  Ensuring that members have access to high-quality practitioners and providers is our focus here as we review the role, composition, and responsibilities of Credentialing Committees and highlight some observations seen by MHR. The Committee requirement applies to all entities that perform credentialing activities except Credentials Verification Organizations (CVO).

What is the role of Credentialing Committees?

Members of Credentialing Committees are participating practitioners who provide advice and expertise for credentialing and recredentialing decisions. They review the credentials of practitioners who do not meet the organization’s criteria for participating in their network(s) and ensure that the files of practitioners who do meet the criteria are reviewed and approved according to the organization’s procedure.   (CR 2)

Depending on the type of your organization, Credentialing Committees may also:

  • Oversee the assessment of practitioners and organizational providers
  • Oversee delegation of credentialing activities
  • Participate in quality improvement
  • Review practitioner information with potential quality of care issues or adverse events
  • Recommend practitioners with adverse events to National Practitioner Data Bank (NPDB) and State Boards
    • Note: Practitioners who review these cases may be a subset of the Credentialing Committee but cannot be limited to only organization-employed practitioners.

 Who makes up an organization’s Credentialing Committee?

 MHR Consultants have observed three areas worth clarifying.

  • Participating practitioners who are part of your organization’s network and are external to the organization must be included as members of the Credentialing Committee.
    • For example, a health plan can include its physician employees on the Credentialing Committee, but they do not take the place of participating external practitioners.
  • The right mix of practitioners must be included among the Credentialing Committee members to ensure a peer-review process when making credentialing decisions.
  • For example, nurse practitioners must be represented on the Committee when evaluating credentials for nurse practitioners.
  • What would not be acceptable, for example, are physicians in the specialty of behavioral health advising an organization on the credentials of an orthopedic surgeon.
  • Practitioners on the Credentialing Committee must be representative of the type of practitioners in the network, not only the members’ needs.

MHR sought clarification from NCQA’s Policy department for a client’s committee composition. In this instance, a Medicaid health plan with a large number of qualified members who are pregnant need pediatricians, family practitioners, and OB-GYN practitioners but may also need practitioners for behavioral health or other medical issues. However, when the organization’s practitioner composition was limited, further justification was needed to support its membership.

  • When organizations are confronted with a limited set of practitioners for the Credentialing Committee, MHR recommends that the organization run a report on the utilization of its network practitioners that could help justify to the NCQA surveyors its committee composition.

Health plans and MBHOs may already have this type of report in their QI or UM program evaluations or the Network Management access and availability reports.

Errors in the composition of Credentialing Committees can result in lower scores for CR 2 on your documented process and lack of presence in your report of committee minutes. Even when the correct composition is in the committee charter, absence from many or all for the variety of other specialties in your minutes can cause a loss of points.

 MHR recommends tracking Credentialing Committee members’ presence and absence over the span of a year and evaluating whether other practitioners should be considered.

Without a good faith effort to reflect attempts at obtaining the wide range of practitioners in the network, your score could be lowered.  The committee is supposed to be a peer review process; without peers, the intent is not met.

Credentialing Committee meeting minutes are a must!

Organizations must provide three sets of meeting minutes (reports) held during your look-back period, which means prior to the survey date for Interim Survey, six months for First Survey, and 24 months for Renewal Survey.

In your minutes, describe in detail for the practitioner files presented for initial credentialing and recredentialing the following:

  • Committee attendees’ names, titles, specialties, network participation status, and how they attended (i.e., in person or by web conference with audio). Note: As specified in the standards, meetings may not be held via e-mail as NCQA wants to see discussion among the participants.
  • list of clean files and files with issues
  • delegation reports
  • complaints
  • quality credentialing metrics
  • what was proposed
  • thoughtful discussion among practitioners, particularly when deciding on practitioners not meeting criteria
  • what was voted upon
  • decisions made

Minutes should not be a “rubber stamp” but show meaningful discussion among the members of the Committee.

For example, suppose there are NPDB actions, sanctions on licensure, or quality concerns. In that case, the minutes must show why the practitioners would still be admitted or continue participation in the network, if applicable.

To reduce risk, the factors for CR 1 A on the criteria for credentialing and recredentialing, plus the decision-making process, must be delineated and adhered to.

Remember!  The committee must credential practitioners before they provide care to members.

Practitioner or Provider? 

While the terms practitioner and provider are sometimes interchanged, NCQA distinguishes between the two.  Practitioners are licensed, certified, or registered individuals by the state to practice independently without supervision or direction and whose individual credentials are evaluated for inclusion in the organization’s network. Providers are institutions or organizations that must meet organizations’ policies for inclusion in the network, including qualifications by state and federal regulatory bodies and an accrediting agency, and are contracted to provide services to members.

Why does this matter?  It is essential to know the following:

  • The type of practitioners brought to Credentialing Committees for credentials review (CR 1A, Factor 1)
  • The type of providers that must be assessed at the organization or facility level (CR 7 B, 7C)
  • Who does not need to be credentialed or verified (CR 1 A and CR 7 B, C, D, and E) 

Need training on Credentialing and Recredentialing?

Clinical and non-clinical staff specialists are often responsible for gathering much of the information from practitioners’ credentialing applications, performing primary source verification, meeting timeliness standards for credentialing recredentialing, developing agendas, recording minutes, and more. Therefore, training is essential to thoroughly understand the current credentialing standards. 

MHR’s Consultants interpret NCQA standards and offer insight gained from working in the industry, consulting, and surveying for NCQA, as many MHR Independent Consultants are also NCQA surveyors.

  • Ask about our Training sessions covering primary source verification, committees, documentation, ongoing monitoring, file reviews, automatic credit, credentialing system controls, insight into common errors, and how to avoid non-compliance with any standard.

Call to Action:

  • Ensure your Credentialing Committee follows a peer-review process.
  • Check your minutes for the level of detail being recorded.
  • Schedule your training.
  • Contact MHR


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