provider representation

Provider Representation

The Basics

Under this standard, your organization must implement a conscious strategy of involving participating providers, at least at some level, in the management of your organization. In addition, that involvement must include participating providers who are relatively typical of the participating providers in your provider network. In particular, that participation should involve including participating providers on committees that deal with clinical and provider payment issues.
Typically, a health network complies with this standard by having participating provider representatives on such committees as credentialing, quality management, and utilization management. Some organizations rely on a multi-purpose committee designed specifically for this purpose, perhaps a physician advisory committee.

Management Tips

Naturally, it is not always easy to get robust participation by physicians and other providers in the management of your company. If you run into such troubles, just make sure that you document your good-faith effort to recruit providers for participation in your committees.
The standard places an emphasis on participating providers from outside your organization. Unless your network is a “staff model” organization in which all of your participating providers are employees, you will need to go outside your employee base to find providers who will meet the requirement of the standard. Within a staff model organization, you’ll need to use providers who are not in network management positions.
As is usually the case, it will not be sufficient to merely have participating provider members of committees; your policies and procedures will need to formally create such involvement.

Accreditation Tips

Desktop Review
At the desktop review phase, submit documents such as

  • policies and procedures that create a role for participating providers on your committees;
  • a list of all committee members including providers, making sure to identify provider credentials and relationship to the organization;
  • examples of recent committee meeting minutes demonstrating actual involvement of participating providers (again, make sure the participating providers are identified in the meeting roster as non-employees).

Validation Review
During the on-site review, the reviewer will examine committee meeting minutes and interview the medical director about how participating providers are recruited for the organization’s committees.

Services

We provide assistance in following areas:

  • Physician organizations, practices, and individual physicians
  • ASCs
  • Anesthesiologists and Interventional Pain physicians
  • CRNAs, NPs, and Pas
  • RNs/LPNs/CNAs