180.021 TMAIT Managed Care Plans

180.021

TMAIT Managed Care Plans: The Texas Medical Association urges the Texas Medical Association Insurance Trust to continue its efforts to assure that any managed care plan it offers adheres to certain guidelines: (1) The managed care organizations must establish fair and equitable physician enrollment criteria and credentialing standards. Board certification and/or residency training should not be sole exclusionary criteria for physicians in networks; (2) Managed care organizations or networks should provide for network practicing physicians to develop and direct peer review and quality management/utilization review programs; (3) Standards and/or criteria for continued participation in networks should be fair and equitable and should be clearly identified and shared with physicians who will be evaluated against such standards; (4) there should be an appropriate due process mechanism for physicians not accepted or deselected from networks, which provides full information as to the reason for selection, a grievance or peer review appeals panel of at least three network practicing physicians to reconsider deselection, and an opportunity for corrective action before deselection from the network. TMA continues to support state and county efforts on behalf of physicians deselected by managed care plans, investigate and publicize the effects of deselection on medical care quality and medical ethics, and identify and publicize the practices which adversely affect the delivery of quality health care services (Substitute Res. 28N, p 140, A-95; reaffirmed CSE Rep. 1-A-05; reaffirmed CSE Rep. 1-A-15).

Last Updated On

October 07, 2016