The facility site review process for MCOs: clinical versus nonclinical reviewers

Managed care organizations (MCOs) conduct provider facility site reviews to promote quality standards in office practice operations and to comply with such regulating agencies as the Joint Commission, various payers, and the Michigan Department of Community Health and statutes such as the Michigan Occupational Safety and Health Act. The results of the facility site reviews are incorporated into the credentialing and recredentialing decision processes for individual practitioners and provider organizations. This study sought to compare the facility site reviews conducted by nurse reviewers who were experienced in quality management of managed care with site reviews conducted by nonclinical staff. In 9 of the 22 sites, the nurse reviewers' scores more accurately represented the primary care physicians' compliance with existing standards and regulations than did those reported by the nonclinical reviewers. This study supports the recommendation that facility site reviews be conducted by nurses experienced in the quality management of managed care.