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Role of Participating Network Physicians

Role of Participating Network Physicians in Health Plans

The American Medical Association (AMA) and the BlueCross BlueShield Association (BCBSA) have worked together over the past year developing the BlueCross BlueShield Association Guidelines on the Role of Participating Network Physicians in Health Plans. The Association offers these guidelines as well-considered recommendations that will promote trust and cooperation between health plans and their participating network physicians.

The 10-point list of guidelines is defined below:

  • Health plans should involve participating network physician representatives in clinically oriented decision-making committees and processes.
  • The credentialing and recredentialing processes in health plans should be implemented by committees with significant representation from participating network physician representatives.
  • To maximize the opportunity for clinical integration and improvement in patient care, all of the specialties participating in a clinical process should be involved in the development of clinical practice guidelines and disease management protocols.
  • Health plans make coverage decisions, but participating network physicians must be able to discuss all treatment alternatives with their patients to enable them to make informed decisions.
  • Members in a health plan and their authorized representatives should have access to a timely, expeditious internal appeals process.
  • Peer review protections should extend to all sites of care.
  • Participating network physician representatives of a health plan should be involved in the design of clinical data collection systems and interpretation of the data so produced to ensure that the information will be meaningful to physicians in their daily practice.
  • Participating network physician representatives should be involved in identifying or developing meaningful quality assessment and improvement measures that can be reported reliably and used to improve clinical performance and health status.
  • All participating physicians should be informed of the identity of their representatives serving on clinically oriented health plan committees.
  • Health plans should provide appropriate indemnity or insurance coverage to participating network physician representatives involved in clinically oriented decision-making committees and processes of the health plan.

Page Modified:May 21, 2012