That the AMA adopt the following policy statements concerning recredentialing by managed care plans:

(1) Recredentialing of a physician or physician group by a managed care plan should not be triggered by a change of practice location within the plan’s contractually defined service area, by a change in practice by a currently credentialed physician to a different group that is also currently credentialed, or to solo practice, or by a change in staff size of the physician group. Any significant resulting change in the number, type, quality or costs of services provided in the practice should be addressed first through physician-directed quality assurance and utilization management mechanisms established in the plan.

(2) Recredentialing of a physician or physician group by a managed care plan should not be required when two or more such plans merge.

(3) Recredentialing or reconsideration of plan participation for a physician or physician group may legitimately be precipitated by a relocation of the practice outside of the plan’s service area.

Policy Timeline

CMS Rep. 8, A-98 Reaffirmed: CMS Rep. 4, A-08 Reaffirmed: CMS Rep. 01, A-18