Medicare Compliance & Reimbursement

The misdeeds of a phony psychiatrist, the forthrightness of a health maintenance organization and a new enforcement approach from the Department of Justice culminated Feb. 13 in an approach to credentialing the feds are touting as a model for managed care organizations nationwide.

The model credentialing policy ironed out between the office of Patrick Meehan, U.S. attorney for eastern Pennsylvania, and Keystone Health Plan East Inc., covers both the initial verification of providers’ licenses, education and board certifications, as well as provides for ongoing audits to ensure appropriate verification procedures have been followed.

“We, like the officials at Keystone, believe the credentialing of health care professionals is an important ingredient in the delivery of managed care,” Meehan says. “Today’s joint agreement creates a significant new protection for patients and is a model that could have an influence across the nation.”

The story began with the trickery of David Temoglie, who fraudulently presented himself as a psychiatrist to Green Spring Health Services, which provided mental health services to Keystone enrollees. Green Spring hired Temoglie, who began treating patients.

It turns out, however, that Temoglie wasn’t really a licensed psychiatrist — a fact that Keystone voluntarily disclosed to the feds once it uncovered the fraud. Meehan’s office prosecuted Temoglie, who was ultimately sentenced to more than three years in prison.

As for Keystone, Meehan’s office says it took a collaborative approach to working out a resolution. Since the health plan came forward with the problem voluntarily, regulators balked at taking enforcement action against it, and ironed out the credentialing policy instead. Meehan says the agreement represents “a groundbreaking approach to addressing care issues and patient concerns.”

To see the policy, go to www.usao-edpa.com/Pr/2003/feb/keystone creden-tialing policy.pdf.