REPORT OF THE COUNCIL ON MEDICAL SERVICE
CMS Report 8 - A-98
Subject: Physician Recredentialing by Managed Care Plans
(Resolutions 715 and 720, I-97)
Presented by: Arthur R. Traugott, MD, Chair
Referred to: Reference Committee G
(Russell C. Raphaely, MD, Chair)
1 At the 1997 Interim Meeting, Resolutions 715 and 720, introduced by the District of Columbia and
2 Virginia delegations respectively, were referred to the Board of Trustees and, subsequently, to the
3 Council on Medical Service. Resolution 715 called for the AMA to “seek by appropriate means
4 available to amend managed care plan requirements, through insurance companies that mandate re-
5 credentialing and re-selection of a physician when he or she makes a practice change or other
6 change in venue,” and requested a report back at the 1998 Annual Meeting. Resolution 720 called
7 for the AMA to “adopt the policy position that when physicians change a practice location or
8 practice arrangement, their status with all managed care plans should remain unchanged; and that
9 there should be no need for re-selection or renewal of the credentialing process for those physicians
10 when such changes occur.”
12 The practice addressed by the resolutions is the reconsideration, at a time other than the normal
13 contract renewal date, of a physician’s or physician group’s participation in a managed care plan.
14 For purposes of this report, this practice will be termed “recredentialing.” The resolutions were
15 referred because of concerns expressed in the Reference Committee that there may be
16 circumstances where such recredentialing is in fact appropriate, and that better delineation of such
17 circumstances may be needed.
19 The terms “change in practice location” or “change in venue” in the resolutions are specific as to
20 the type of circumstance addressed. However, the terms “practice change” and “practice
21 arrangement” are broad, and could encompass a host of different changes that may relate either to a
22 physician’s professional qualifications or competence—such as board certification in an additional
23 specialty or the termination of hospital staff privileges—or to business arrangements addressed in
24 the physician’s contract, such as the amount of malpractice insurance carried or the level of
25 payment for services. Recredentialing may well be appropriate for some changes of this nature and
26 inappropriate for others.
28 Further elaboration as to the scope and nature of the practice changes addressed by the resolutions
29 was not received from either of the sponsors. However, the Council notes that the “whereas”
30 portions of both resolutions are identical in singling out “a change in address or a change in group
31 size” as circumstances triggering recredentialing, and believes that the intent was to oppose these
32 specific practices.
CMS Rep. 8 - A-98 -- page 2
1 In June 1997, the AMA, through its Division of Representation, distributed a “Model Managed
2 Care Medical Services Agreement” to the House of Delegates and members of the Federation. The
3 model provisions, addressing such issues as without-cause termination, mediation or arbitration,
4 promptness of payment, patient protections, credentialing and utilization review are intended to
5 assist physicians contemplating contractual relationships with health plans in reaching agreements
6 that protect the legitimate interests of both parties. However, the Model Agreement does not
7 address the specific issues concerning changes in practice location or group size raised by
8 Resolutions 715 and 720. Policy H-285.984, (AMA Policy Compendium), acknowledges the right
9 of health plans to develop and use credentialing (and recredentialing) criteria related to the number,
10 geographic distribution and specialties of physicians needed. The policy also advocates that full
11 disclosure of such criteria be made to physicians applying to and participating in the plan, and that
12 the plan provide procedural and due process protections in the credentialing of providers. Based on
13 this policy, the Council on Medical Service believes that the following guidelines should apply to
14 the recredentialing of physicians or physician groups based on changes in practice location or in
15 group size:
17 A change in the physician’s or physician group’s practice location within the plan’s
18 contractually defined service area, or a change in practice by a currently credentialed physician
19 to a different group that is also currently credentialed, should not in itself precipitate
20 recredentialing of that physician or group. Any significant resulting change in the number,
21 type, quality or costs of services provided in the practice should be addressed first through
22 physician-directed quality assurance and utilization management mechanisms established in
23 the plan.
25 A move of the physician’s or group’s practice location out of the plan’s service area constitutes
26 legitimate grounds for recredentialing or reconsideration of physician or group participation,
27 based on concerns for access to services by plan enrollees.
29 An increase or decrease in staff size of a physician group should not in itself precipitate
30 recredentialing of that group or of individual physicians practicing within the group. Any
31 significant resulting change in the number, type, quality or costs of services provided in the
32 practice should, again, first be addressed through established quality assurance and utilization
33 management mechanisms in the plan.
35 The Council will continue to review issues related to other aspects of recredentialing and submit
36 further reports as the need may arise.
40 The Council on Medical Service recommends adoption of the following in lieu of Resolutions 715
41 and 720 (I-97), and that the remainder of this report be filed:
43 1. That the AMA adopt the following policy statements concerning recredentialing by managed
44 care plans:
CMS Rep. 8 - A-98 -- page 3
1 a) Recredentialing of a physician or physician group by a managed care plan should not be
2 triggered by a change of practice location within the plan’s contractually defined service
3 area, by a change in practice by a currently credentialed physician to a different group that
4 is also currently credentialed, or to solo practice, or by a change in staff size of the
5 physician group or by a change in staff size of the physician group. Any significant
6 resulting change in the number, type, quality or costs of services provided in the practice
7 should be addressed first through physician-directed quality assurance and utilization
8 management mechanisms established in the plan.
10 b) Recredentialing of a physician or physician group by a managed care plan should not be
11 required when two or more such plans merge.
13 c) Recredentialing or reconsideration of plan participation for a physician or physician group
14 may legitimately be precipitated by a relocation of the practice outside of the plan’s service
17 2. That the AMA advocate these policies with managed care plans and national managed care and
18 insurance organizations through all appropriate channels.
20 3. That the AMA strongly encourage organizations and entities that accredit health plans to
21 include plan compliance with these recredentialing policies in their evaluation criteria.
23 4. That the AMA include provisions addressing these policies in its “Model Managed Care
24 Medical Services Agreement.”