TABLE 3-2 Overview of Regulatory Requirements: VHA, DOD TRICARE, and IHS

 

VHA

DOD TRICARE

IHS

Target entities

Institutional providers and clinicians that provide care to VHA beneficiaries

Institutional providers, clinicians, and networks that serve TRICARE beneficiaries

IHS-funded institutional providers and clinicians

Requirements

VHA hospitals, facilities, and other providers must be accredited by JCAHO or some other accrediting group.

Clinicians must be credentialed according to VHA policies and JCAHO standards.

An external review program covers all VHA facilities. The current contractor is the West Virginia Medical Institute, Inc.

Institutional providers, clinicians, and networks must be Medicare-approved (where relevant). Except for operational ambulatory clinics (treating active-duty personnel only), all “fixed” hospitals and freestanding ambulatory clinics must be accredited by JCAHO or some other applicable accrediting group

A national external review program is carried out by KePRO, Inc.

Most IHS facilities are accredited by JCAHO or the Accreditation Association for Ambulatory Health (AAAHC), or certified by CMS (whichever is relevant).

Must meet the external review requirements of the Medicare and Medicaid programs.

Enforcement

Failure to comply disqualifies clinicians from serving VHA beneficiaries.

Deficiencies in compliance generally lead to corrective authorized provider.

Failure to meet the quality standards and certification requirements may result in termination of payments and identification as a non-action initiatives.

Deficiencies in compliance generally lead to corrective action initiatives.

 

SOURCES: Department of Defense, 1995, 2001; Indian Health Service, 2001b; Pittman, 2002; and Veterans Administration, 2001.

the supply of primary care providers); (2) the degree of interdependence and authority of various types of health care professionals (Cooper et al., 1998); (3) the ability to deliver care through multidisciplinary teams (e.g., proscriptive state scope-of-practice acts limit innovation in redefining roles and functions performed by nonphysician health care professionals) (Sage and Aiken, 1997); and (4) the development of approaches to care



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