Credentialing

As a physician-hospital organization, participation in Methodist Health Partners, Inc. (MHP) is limited to qualified providers affiliated with:

• Methodist Fremont Health (MFH)
• Methodist Jennie Edmundson Memorial Hospital (MJEMH)
• Methodist Women’s Hospital (MWH)
• Nebraska Methodist Hospital (NMH)
• Midwest Surgical Hospital

Credentialing is the process used to develop and maintain a network of practitioners qualified to deliver appropriate, medically necessary health care services to patients. The credentialing program involves the collection, verification, and review of information necessary for the selection and retention of practitioners for the MHP network.

The credentialing process typically includes researching practitioners education, licensure, National Practitioners Data Bank query, DEA certification, malpractice history, and past work history.

Methodist Health Partners provides a high standard of credentialing by following National Committee for Quality Assurance (NCQA) guidelines unless superseded by state or federal law.

Since 2003, MHP has maintained Delegated Credentialing Agreements with our contracted payers/networks, and we consistently receive the highest marks possible on our credentialing files. The Credentialing Committee is made up of at least four physicians with multi-specialty backgrounds and currently includes the below members.

Credentialing Committee Members

• Michael Romano, MD, Chairman
• Thomas McGinn, MD
• Stephen Lim, MD
• Eric Schulte, DO
• Jessica Prusa Flores, MD
• Chad Reade, MD

Credentialing Policies and Procedures, including the Eligibility Requirements below, are reviewed annually.

Policy: CR 1.1

Title: Eligibility

A. Eligible Practitioners.  Physicians (MDs, DOs, and podiatrists) are eligible to participate in MHP if they meet the criteria set out at CR 1.2, including the criteria for physician practitioners at CR 1.2.C:

The following non-physician Practitioners are eligible to participate if they meet the criteria set out at CR 1.2, including the criteria for non-physician practitioners at CR 1.2.C.

• Advanced Practice Registered Nurses (who are not Behavioral Health Practitioners)
• Behavioral Health Practitioners, including:
  • Advance Practice Registered Nurses
  • Doctoral Psychologists who are state certified or state licensed
  • Master’s level clinical social workers who are state certified or state licensed
  • Master’s level clinical nurse specialists or psychiatric nurse practitioners who are state certified or state licensed
  • Other behavioral health care specialists who are licensed, certified or registered by the state to practice independently
• Certified Nurse Midwives
• Certified Registered Nurse Anesthetists
• Physician Assistants
• Optometrists
• Chiropractors
• Audiologist
• Medical Nutrition Therapist
• Physical Therapists
• Occupational Therapists
• Speech Therapists
• Licensed Dietitian or Medical Nutrition Therapist

Additional practitioner types are eligible for participation only upon review and approval by the MHP Board of Directors.

B. Ineligible Practitioners.

The following are not eligible to be credentialed under MHP:

• Locum Tenens Physicians
• Temporary or Provisionally licensed practitioners

Policy:  CR 1.2

Title:      Credentialing Criteria – Practitioners

Eligible practitioners must continuously meet the following criteria for MHP participation:

Criteria:

A. The practitioner must hold an unrestricted license to practice his or her profession in each state in which he or she provides patient care.

B. The practitioner must maintain malpractice insurance with minimum amount limits of either $1,000,000/$3,000,000 or of $500,000/$1,000,000 with participation in the Nebraska Excess Liability Fund.

C. If a physician, the practitioner must meet one of the following:

1. Be employed by Nebraska Methodist Health System ("NMHS") or an affiliate; or
2. Be a member of the medical staff of NMH, MJE, or MFH in the category of Active; or
3. Be a member of the medical staff of NMH, MJE, or MFH  in the category of Courtesy or Consulting, and maintain a substantial practice affiliation with NMH, MJE, or MFH as defined from time to time by MHP; or
4. Be employed or contracted by a group practice, which includes a participating MHP Physician with whom the MHP participating physician shares call; or
5. Be employed or contracted by a group practice, which includes a MHP Physician who is a member of the medical staff of NMH, MJE, or MFH in the category of Active, and who provides substantial medical services to patients of the group practice in its offices, upon the request of the MHP Physician for participation by the applicant; or
6. Be a psychiatrist to whom a MHP Physician desires to refer MHP patients needing the services of a psychiatrist, upon request of the MHP Physician desiring to make such referrals; or
7. Be a physician in a specialty designated from time to time by MHP which does not have a substantial practice affiliation with any hospital and to whom a MHP Physician desires to refer patients needing the services of such physician, upon request of the MHP Physician desiring to make such referrals; or
8. Be employed or contracted primarily to provide medical services at an urgent care facility approved by MHP.

Physicians other than in the first three categories must provide MHP with individual performance information upon request and allow MHP to audit a sampling of practice medical records.

If not a physician, the practitioner must:

1. Provide services through a group practice that includes a participating MHP Physician; or
2. Be employed by, or contracted to provide services by, Nebraska Methodist Health System or an affiliate; or
   1. Be a behavioral health practitioner who:
      provides services through an existing MHP group practice that includes a participating MHP practitioner (shall no longer remain eligible if practitioner terminates from said group practice); or
   2. does not have a substantial practice affiliation with any hospital and to whom a MHP Physician desires to refer patients needing the services of such behavioral health practitioner, upon request of the MHP Physician desiring to make such referrals.

The MHP Board may waive Criteria C upon a showing of good cause in furtherance of the objectives of MHP after considering the recommendation of the Credentials Committee.

Ineligible Practitioners

The following are not eligible to be credentialed under MHP:

•    Locum Tenens Physicians

•    Temporary or Provisionally licensed practitioners