Independent Physician Network’s Credentials Committee oversees the process of authenticating the qualifications of licensed medical professionals to assess their experience, education, and training for legitimacy. Credentialing is important for physicians and other health care practitioners who need to bill insurance companies and receive compensation for their health care services. The Credentials Committee is comprised of IPN member physicians who practice in various specialties. Currently, five IPN member physicians serve on the Credentials Committee, as well as the IPN Medical Director.

With IPN, there is neither a fee for credentialing or re-credentialing services nor a fee to become an IPN member or contracted provider. Applications to become an IPN member physician, contracted provider, or to be recredentialed through IPN are presented to and reviewed by the Credentials Committee for recommendation to the IPN Board of Directors.

IPN’s Credentials Committee follows the standards set by the National Committee on Quality Assurance (NCQA) when reviewing provider files. The criteria reviewed by the IPN Credentials Committee includes:

• Education
• Board Certification
• Work History
• Current State of Wisconsin License
• Current Malpractice Insurance
• Current DEA License
• Clinical Privileges
• Sanction History
• Claims History

The standards IPN follows to credential its member physicians and contracted providers exceed the NCQA standards as those requirements only include verification of current documents—State of Wisconsin License, Malpractice Insurance, and DEA License—at the time of credentialing/recredentialing. IPN member physicians and contracted providers are recredentialed every three years.

Currently, IPN provides credentialing services for its member physicians and contracted providers for each of IPN’s twelve contracted health plans. For those health plans, member physicians and contracted providers do not have to submit credentialing information on their own, saving both time and money. IPN also submits updated member physician/contracted provider information monthly to these contracted plans.

Another way IPN exceeds NCQA standards is by conducting required physician office site visits to all new physicians’ offices, including those offices opened by a provider after becoming an IPN member physician. These site visits benefit our member physicians and their staff by ensuring they meet all medical office standards, which, in turn, benefits their patients. During site visits, IPN’s Senior Provider Relations Representative also reviews IPN’s contracted health plans and the contact, authorization, referral, and claims information for each plan with the office staff.

Medical Review

Independent Physician Network’s Medical Review Committee convenes quarterly to conduct evaluations of many aspects important to all member physicians, including conducting provider appeal reviews. By reviewing statistical data provided by Trilogy to identify trends and recommend improvement strategies, the Medical Review Committee not only supports and encourages the requirements and standards mandated by Trilogy and the Department of Health Services (DHS) but also ensures those standards are upheld by all IPN member physicians. The Medical Review Committee is responsible for providing oversight for operations, evaluations, and monitors Utilization Management activities on an annual and continuous basis.

The Medical Review Committee ensures that all IPN member physicians maintain good standing. The Committee is important for all member physicians and other healthcare practitioners as it conducts provider appeal reviews and considers aspects such as:

• Unusual practice patterns,
• Providers with multiple member complaints
• Providers with complaints regarding significant quality of care issues
• Appeals or potential fraud issues

By following appropriate policies and procedures, as well as promoting the IPN mission statement to provide high-quality care at an effective cost for all patients, we can ensure all member physicians are in good standing. Through our mission statement and high standards, IPN supports and encourages independent practitioners.

Currently, the Medical Review Committee is comprised of nine IPN member physicians who practice in various specialties, including the IPN Medical Director, Assistant Medical Director, VP of Medical Affairs, Director of Quality and Clinical Services (non-voting), and Executive Director (non-voting). The Medical Review Committee reports directly to the IPN Board of Directors.

Medicare

Medicare Management Committee

Independent Physician Network’s Medicare Management Committee convenes quarterly to oversee Medicare administrative functions, including the provider integrity program and Office of Inspector General (OIG) sanction reviews. The Committee is also responsible for monitoring the financial operations of IPN’s Medicare agreements and the approval of all Medicare related policies and procedures to ensure all member physicians are in good standing. Currently, the Committee consists of eight member physicians, including the VP of Medical Affairs (Chair), Assistant Medical Director, six additional IPN member physicians, Director of Quality and Clinical Services (non-voting member), and Executive Director/CEO (non-voting member).

Together, the Medicare Management Committee develop and implements the IPN annual compliance plan, compliance monitoring tools, compliance reports, and compliance training. The Committee is responsible for maintaining necessary infrastructure to detect potential violations of the Medicare compliance program, investigating suspected violations, and developing corrective actions plans when violations are discovered.

Medicare Care Coordination/Quality Committee

Independent Physician Network’s Medicare Care Coordination/Quality Committee convenes quarterly to review the overall quality performance of IPN’s Medicare programs and address any potential quality of care issues. Currently, the Committee consists of seven member physicians, including the Assistant Medical Director (Chair), VP of Medical Affairs, five additional IPN member physicians, Director of Quality and Clinical Services (non-voting member), and Executive Director/CEO (non-voting member).

The Medicare Care Coordination/Quality Committee is responsible for creating programs to support Medicare quality measures and developing “best practices” by applying evidence-based protocols. To ensure all IPN member physicians are providing optimal care, the Committee analyzes and identifies opportunities to improve efficiencies in delivering care to Medicare patients. The Committee also oversees the review and adoption process for the clinical practice guidelines for the specific disease categories and determines high-risk membership and develops applicable action plans.