Though VBH-PA is able to resolve most provider credentialing and quality issues through consultation and education, occasionally further action is necessary to ensure quality service delivery and protection of members. The National Credentialing Committee (NCC) may impose provider sanctions for issues related to member complaints/grievances, quality of care or provider contract compliance. VBH-PA will comply with all applicable local, state and federal reporting requirements regarding professional competence and conduct to ensure the highest quality of care for our members. A provider has the right to appeal any sanction through the ValueOptions Provider Appeals Committee (PAC)/Fair Hearing Appeals process. The following is a list of sanctions available to the NCC and the PAC:
Type |
Definition |
Consultation |
A call is placed to notify the practitioner of the alleged action or incident. The practitioner will be provided with an explanation of possible sanctions if corrective actions are not taken. The call will be documented to include the date and subject for consultation. A copy of the consultation will be placed in the practitioner’s file. Appropriate educational materials will be sent via certified mail. |
Written Warning |
A written notice is sent to the practitioner notifying him/her of the alleged action or incident. Possible sanctions, if corrective actions are not taken, will be explained. A copy of the letter is retained in the practitioner’s file; educational material is sent via certified mail. Corrective action will be monitored as necessary. |
Second Warning/Monitoring |
At the discretion of the Medical Director, a second written notice may be sent to the practitioner and a copy of such letter shall remain in ValueOptions’ file. The practitioner can be placed on monitoring when data indicate non-conformance with standards and if ValueOptions determines it is in the member’s interest ValueOptions may elect to suspend new member referrals, new patient authorizations and/or redirect all current patients to other providers. The practitioner will be given written notice via facsimile and certified mail of the issues for which he/she is being suspended. A copy of the letter is placed in the practitioner’s file. The suspension may last for a period of 30 days during which time an investigation may take place. The NCC may extend this time period as necessary to gather additional information. Suspension is only used for serious infractions that are probable cause for termination. |
Termination |
The practitioner may be terminated from the network. Termination requires NCC action. The practitioner will be given written notice via facsimile and certified mail that he/she is being terminated from the network and the reason for the termination. A copy of the letter is put in the practitioner’s file. Members in care will be notified and given assistance for referral to a new practitioner for continuing care, as necessary. |
| Type |
Definition |
Consultation |
A call is placed to notify the head (e.g., CEO) of the organization of the alleged action or incident at issue, including an explanation of possible sanctions if corrective actions are not taken. The call will be documented to include the date and subject for consultation; a copy of the consultation will be placed in the organization/facility file. Appropriate educational material will be sent via certified mail. |
Written Warning |
A written notice will be sent to the head (e.g., CEO) of the organization notifying him/her of the alleged action or incident. An explanation will be given of possible sanctions if corrective actions are not taken. A copy of the letter will be placed in the organization/facility file and appropriate educational materials will be sent via certified mail. Corrective action will be monitored as necessary. |
Second Warning/Monitoring |
At the discretion of the Medical Director, a second written notice may be sent to the head (e.g., CEO) of the organization/facility and a copy of such letter shall be included in ValueOptions’ file. Additionally, organizational providers may be placed on monitoring when data indicates a program is out of conformance with ValueOptions standards and if ValueOptions determines it is in the member’s best interest to allow the provider to continue active participation in the network. An action plan will be provided consisting of steps that, when taken, will remedy the deficiencies or concerns that created the need for monitoring. The provider is expected to make a best effort to comply with the monitoring action plan. If an action plan has been sent, the provider is expected to notify ValueOptions in writing of the status of the issue for which monitoring was initiated at the end of the action plan timeline, or sooner if applicable. Monitoring may last for up to 90 days at which time it may be continued depending on the status of the issue. The organization/facility is expected to keep ValueOptions updated in writing of all changes in the issue/concern that triggered monitoring. |
Suspension |
The organization/facility may be suspended from network participation pending resolution of issues raised. Suspension requires NCC action. During suspension, ValueOptions may elect to suspend new member referrals, new patient authorizations and/or redirect all current patients to other providers. The head (e.g., CEO) of the organization/facility will be given written notice via facsimile and certified mail of the issues for which it is being suspended. A copy of the letter is placed in the organization/facility file. The suspension may last for a period of 30 days during which time an investigation may take place. The NCC may extend this time period as necessary to gather additional information. Suspension is only used for serious infractions that are probable cause for termination. |
Termination |
The organization/facility may be terminated from the network. Termination requires NCC action. The organization/facility will be given written notice via facsimile and certified mail that the organization/facility is being terminated from the network and the reason for termination. A copy of the letter will be placed in the organization/facility file. Members in care will be notified and given assistance for referral to a new provider for continuing care, as necessary. |
