QUESTION:
In the Chalifoux case summarized in this week’s Health Law Express, the physician’s participation agreement with the health plan required him to have clinical privileges at an in-network hospital. Is it common for health plans to require participating physicians to be appointed to the Medical Staff and have clinical privileges at an in-network hospital?
ANSWER FROM HORTYSPRINGER ATTORNEY
CHARLIE CHULACK:
While we here at Horty, Springer & Mattern don’t typically negotiate participation agreements between individual physicians and health plans, we do a significant amount of work on delegated credentialing agreements between hospitals or physician groups and insurers. Since these agreements delegate credentialing functions for health plan enrollment to hospitals or groups, they contain many of the same requirements as participation agreements. In our experience, insurers have moved away from a strict requirement that a physician have clinical privileges (including admitting privileges) at a participating hospital. This makes sense since many physicians practice solely in an outpatient setting and have no need for Medical Staff appointment or clinical privileges at a hospital. Also, many hospitals rely heavily on hospitalists to manage the care of inpatients, reducing the need for outpatient physicians to have hospital privileges. What we typically see in these delegated credentialing agreements is a requirement that participating physicians have either admitting privileges at an in-network hospital or an admitting relationship with a physician at such a hospital. During negotiations of these delegated credentialing agreements, most insurers use an expansive interpretation of an admitting relationship – thus, if the physician is affiliated with an in-network hospital and the hospital has a hospitalist service that is primarily responsible for admitting patients, that is enough to satisfy this requirement.
If you have a quick question about this, e-mail Charlie Chulack at cchulack@hortyspringer.com