April 19, 2005

Do You Need to Be Credentialed by Health Plans? See what the health plans’ accreditation agency requires.

Managed care payers (health plans) do not need to credential most anesthesiologists individually. The National Committee for Quality Assurance (NCQA), the major organization that accredits health plans, does not require plans to credential hospital- and surgery center-based specialists under certain circumstances. If these specialists do not have independent relationships with the plan, but instead provide care for the plan’s patients as a result of the patients’ choosing the particular hospital or other facility, the plan may rely on the facility’s own credentialing.

The section on Credentialing Policies (CR1) in the NCQA 2004/2005 Managed Care Organization Standards and Guidelines cites anesthesiologists as an example of the specialists to whom this credentialing exception applies. It also states that anesthesiologists with pain medicine practices, even if hospital based, may need to be credentialed because of an independent relationship with the health plan.

Anesthesiologists who aren’t credentialed generally have a hard time collecting payments from a health plan. This may be a serious problem for a practice that hires anesthesiologists fresh out of training or from a different geographic area. Reminding the health plan that the NCQA does not require it to credential most anesthesiologists independently could alleviate the problem.

Click here for a copy of the NCQA credentialing guidelines.