Contracted Provider Dismissal Policy

Policy: Contracted Provider Dismissal

Policy Number: 310 Policy Section: Quality
Owner: Kevin M. Ramotar, Psy.D. Approved By: Paul Vogelman, COO
Effective Date: 3/13/2023 Date of Last Review: 3/21/2023

SUD Specialty Group -- CA; Mental Health Specialty Group, P.A.; Mental Health Specialty Group NJ, PC; and Mental Health Specialty Group KS, P.A. (collectively, the "Group") contracts with Path CCM, Inc. d/b/a Rula Health ("Rula") for management and administrative support services. This policy applies to the Group and Rula.

Policy Statement

Rula is committed to the delivery of high-quality care to patients and ensuring compliance with all relevant laws and regulations. In the event that a clinical provider is found to have violated these quality expectations and compliance standards, the organization has a responsibility to investigate, intervene, and take action, ranging from educational coaching to dismissal from the network.  

 

This policy applies only to 1099 contractor providers working with the Group.  Further, this policy sets out the procedures to be followed when dismissing contracted providers for compliance, quality, credentialing, and/or clinical care issues, in addition to outlining the steps taken to manage the patient experience after provider dismissal.

Applicability

This policy applies to all contracted providers at Rula involved in patient care.

 

Definitions

 

Policy

A. Expectations

  1. Providers must hold an unrestricted active license in good standing to practice psychotherapy and maintain malpractice insurance (at minimum $1,000,000/$3,000,000).  Any lapses in licensure and insurance will result in dismissal from the Group.
  2. Providers must comply with all applicable federal and state regulations of respective clinical licensure, as well as internal Group policies and procedures. 
  3. Providers are expected to meet Rula’s designated quality standards.  Quality issues may be identified through regular quality audits, peer review, patient complaints, and other means of monitoring clinical care.  All providers will have access to their individual quality data through the Clinical Quality Snapshot dashboard to self-monitor clinical performance.  Rula will notify providers prior to any updates if/when changes are made to quality standards and metrics.
  4. Providers are expected to abide by and follow the Rula’s Compliance Plan (ex. completing HIPAA training) and Code of Conduct. Violation may be grounds for dismissal or termination of a contractual relationship with the Group.

B. Reporting

  1. Any concerns related to compliance, quality, credentialing, or clinical care should be reported to the Clinical Quality leadership. This includes, but is not limited to, concerns related to patient safety, quality of care issues, patient experience, professionalism, and failure to follow established protocols and maintain all requirements for independent practice.

C. Investigation

  1. Leadership will conduct a thorough investigation of any concerns reported. This may include interviewing patients/providers, reviewing medical records, data analysis, and/or consulting with external experts as necessary.
  2. While the investigation is taking place, a provider may be “paused” from receiving new patients.
  3. Based on the findings of the investigation, Leadership will assess the issue on the criteria below.  
    1. Outcome: The impact of the concern on patient health, safety, and well-being, including the severity and potential/actual of any harm or injury to the patient
    2. Frequency: The frequency with which the concern has occurred, including whether it is a one-time or ongoing issue.
      1. Frequency will also encompass consideration of other issues related to the provider over the past 12 months
    3. Standard of Care: The extent to which the concern is relevant to current clinical practice standards and guidelines.  Additionally, this criteria includes the extent to which the concern is consistent with evidence-based practice and available research.
    4. Provider Intent: The provider's intentions and motivations, including whether the concern was the result of intentional wrongdoing or a mistake.
    5. Professional Ethics: The assessment of the extent in which the concern violates the industry ethics
    6. Practice Expectations: The extent to which the concern violates Rula’s practice and quality expectations
    7. Compliance: The extent of which the concern violates Rula’s compliance standards and/or legal and contractual requirements such as fraudulent billing or failure to comply with payer requirements. 
    8. Patient Factors: Patient-related factors that may have contributed to the concern, including medical history, underlying conditions, and patient behavior.
    9. System Factors: System-related factors that may have contributed to the concern, including processes, policies, and protocols.
    10. Provider Performance History: The provider's overall performance, including past incidents, history of quality issues, and feedback from patients and other healthcare staff.
      1. Past Coaching plans, completed and current, and outcomes will factor into this criteria
    11. Timeframe: The timeframe in which the concern occurred, including how long it took for the issue to be identified and reported.
  4. Findings will be classified by severity by the Clinical Quality leadership.
  5. After the assessment is complete, Leadership will make recommendations based on the following actions, in which multiple may be selected:
    1. No action: No or insufficient evidence of concern
    2. Correction of Documentation: Require the provider in correcting any inaccuracies or inconsistencies in their documentation to ensure compliance with relevant policies and regulations.
    3. Information: Provide additional information to the provider on the specific issue, related policies and procedures, and best practices delivered by a Rula Quality Coach
    4. Coaching Improvement Plan: Develop a coaching plan with designated timelines that outlines specific steps the provider must take to address the issue and improve their performance.  The provider is encouraged to work directly with a Rula Quality Coach to support improvement.
      1. At completion of the Coaching Plan, the Clinical Quality leadership will review progress and may extend the plan or recommend dismissal.
    5. Professional Development: Encourage the provider to pursue professional development opportunities to improve their skills and knowledge.
    6. Pausing New Patients: Implement pause of new patient intakes until the issue is resolved.
    7. Dismissal: In certain cases, termination of the provider’s contract with the Group and removal from the network may be necessary if the issue cannot be resolved through other options.  
  6. If the investigation determines that the provider has violated any quality, compliance, or clinical care standards and dismissal is not recommended, the provider will be given written notice of the violation and given an opportunity to correct the issue.  A Quality coach may be assigned to provide education and support to mitigate the likelihood of recurrence.
  7. If the provider fails to correct the issue within the designated timeline, or if the violation is classified as severe, the provider may be dismissed from the network.

D. Dismissal

  1. If the recommended action is dismissal, a representative of the appropriate Leadership team (i.e., Compliance, Clinical Quality, Credentialing) will notify the provider by telephone and follow-up in writing.  The provider has the opportunity to appeal the decision (Section F).
  2. Providers must be discontinued from patient care immediately after notification, regardless of appeal status.
  3. Depending on the circumstances (i.e. severity of the issue), the Group will decide if the provider may rejoin Rula in the future, no sooner than 6 months from the dismissal date.
  4. The dismissal will be reported to the applicable payers.  There may be an additional report to relevant licensing and certification boards depending on legal requirements.

E. Management of Patient Experience

  1. In the event that a provider is dismissed, the organization will take steps to ensure that patient care is not compromised. This will include the Rula Support team offering reassignment of patients to another clinician, providing additional support and resources as needed, and ensuring that patients are informed of the situation as soon as possible and prior to the next scheduled appointment to minimize any disruption in the continuity of care.
  2. The patient will be shared general information about their provider’s departure, and support will coordinate rematching.
  3. A representative from Leadership will complete and submit the internal Rula dismissal form to ensure that the provider is removed from the network and future correspondence.  All steps involved in processing a provider’s departure from Rula will be expedited in the case of a dismissal. 

F. Appeal Process

  1. Providers will be given the right to appeal their dismissal within 14 days of receiving written notice of their dismissal.
  2. The provider must submit a written appeal to the Clinical Quality leadership at quality@rula.com.
  3. The written appeal must include the reasons for the appeal and any relevant documentation or evidence.
  4. Members of the Clinical Quality leadership will review the appeal with leaders from other teams as indicated, and any relevant documentation or evidence.
  5. The Clinical Quality leadership may request a meeting with the provider to discuss the appeal and gather additional information.
  6. The Clinical Quality leadership will make a decision on the appeal and notify the provider in writing within 30 days of receiving the appeal.

 

Attachments: 

A: Quality Concern Form

 

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