Ama Policy

Qualifications and Credentialing of Physicians Involved in Managed Care H-285.991

Credentialing-Due Process-Denial of Contract, Termination, Termination-Due Process

1. AMA policy on selective contracting is as follows:

(a) Health plans or networks should provide public notice within their geographic service areas when applications for participation are being accepted.

(b) Physicians should have the right to apply to any health care plan or network in which they desire to participate and to have that application approved if it meets physician-developed objective criteria that are available to both applicants and enrollees and are based on professional qualifications, competence and quality of care.

(c) Selective contracting decisions made by any health delivery or financing system should be based on an evaluation of multiple criteria related to professional competency, quality of care, and the appropriateness by which medical services are provided. In general, no single criterion should provide the sole basis for selecting, retaining, or excluding a physician from a health delivery or financing system.

(d) Prior to initiation of actions leading to termination or nonrenewal of a physician’s participation contract for any reason the physician shall be given notice specifying the grounds for termination or nonrenewal, a defined process for appeal, and an opportunity to initiate and complete remedial activities except in cases where harm to patients is imminent or an action by a state medical board or other government agency effectively limits the physician’s ability to practice medicine. Participation in a physician health program in and of itself shall not count as a limit on the ability to practice medicine. Our AMA supports the following appeals process for physicians whose health insurance contract is terminated or not renewed: (i) the specific reasons for the termination or nonrenewal should be provided in sufficient detail to permit the physician to respond; (ii) a name and address of the Director of Provider Appeals, or an individual with equivalent authority, should be provided for the physician to direct communications; (iii) the evidence or documentation underlying the proposed termination or nonrenewal should be provided and the physician should be permitted to review it upon request; (iv) the physician should have the right to request a hearing to challenge the proposed termination or nonrenewal; (v) the physician or his/her representative should be able to appear in person at the hearing and present the physician’s case; (vi) the physician should be able to submit supporting information both before and at the fair hearing; (vii) the physician should have a right to ask questions of any representative of the health insurance company who attends the hearing; (viii) the physician should have at least thirty days from the date the termination or nonrenewal notice was received to request a hearing; and (ix) the hearing must be held not less than thirty days after the date the health insurer receives the physician’s request for the review or hearing.

2. The qualifications, responsibilities, and duties of physicians employed as medical directors of managed care plans should be developed on an individual basis by the plan concerned. Physicians who participate in the plan, or the plan’s medical staff, if one is so designated, should participate in developing such qualifications, responsibilities, and duties.


Policy Timeline

CMS Rep. B, A-93 BOT Rep. I-93-25 Reaffirmed: Sub. Res. 704, I-94 Reaffirmed: Sub. Res. 701, I-95 Reaffirmed by Rules & Credentials Cmt., A-96 Reaffirmed: CMS Rep. 3, I-97 Reaffirmed by Res. 108, A-98 Reaffirmation A-01 Appended: CMS Rep. 8, A-10 Reaffirmed: Res 119, A-14 Modified: Res. 708, A-14 Reaffirmation A-14 Reaffirmed: CMS Rep. 4, I-14 Reaffirmed: Res. 116, A-18