7/16/14&
1&
Brought(to(you(by(Progressive(A(webinar(series(that(keeps(you(in(the(know(
Debra Stinchcomb, RN, BSN, CASC Progressive Huddle Monday July 21, 2014 11AM PT/2PM ET
Credentialing Pearls: A Systematic Approach to Compliance
Where the process begins!
• Bylaws • Define who can apply for privileges (MD, DO,DDS, DPM,
Doctor of Optometry, Chiropractor, AHP)
• Define requirements for acceptance into medical staff for initial appointment and reappointment
• Outline responsibility of medical staff
• Define categories of appointments (active, temporary, emergency, provisional, consulting)
• Define malpractice requirements
• Define approval and fair hearing process in case of denial or suspension/limitation
7/16/14&
2&
Available on eSupport: Operations/Staffing
Application Packet
Credentialing starts with an application packet
At a minimum Practitioner completes:
• Application • Demographic information • Education, Board Certification • Evidence of training and work history (CV) • Hospital Affiliations
Application Packet
• Liability Questionnaire (yes/no) • Claims history where a decision was rendered against
the practitioner (practitioner should submit a summary)
• Licensure issues (revocation/suspension)
• Complaints filed with local, state, national professional society or licensure board
• Other professional privilege issues (suspension from hospital or health plan)
• DEA and state controlled drug substance registration action
• Disclosure of Medicare/Medicaid sanctions
• Conviction of criminal offense
• Current physical/mental health or chemical dependency problems
7/16/14&
3&
Submitted with Application
• Peer Reference List
• Health Statement
• Release of information
• Signed statement attesting to the correctness of the application
• Delineation of privilege request form (DOP)
Submitted with Application
• State Medical License
• State CDS, if applicable
• DEA
• Malpractice Face Sheet (practitioner name, policy number, amount of coverage per incident and aggregate, expiration date, name and address of insurance company)
Additional Requests
• BLS, ACLS
• TB test
• Specific reference requests
• Candidate interviews
7/16/14&
4&
Application Complete!!
Verification of Application
• Three methodologies to verify credentials: • Primary Source Verification
• Reliable Secondary Source Verification from an organization that has documented primary source verification
• CVO which meets accrediting body requirements
Primary Source Verification
• Used for verification of licensure, certification, education and training, hospital affiliations, sanctions
• Occurs with the original source of information
• Verification must be in writing
• Communication modes: • Direct correspondence via letter
• On line verification
• Telephone verification
7/16/14&
5&
Examples of Primary Sources
• State Medical Board Web Site
• DEA: https://www.deadiversion.usdoj.gov/webforms/validateLogin.jsp
• OIG for Medicare Sanctions: http://exclusions.oig.hhs.gov/
• Institutions where practitioner completed programs. Verify dates of attendance and successful completion.
Reliable Secondary Source
• Verification is from an organization that has documented primary source verification and has been designated the role of communicating the credentials information. This agency becomes acceptable to use as a primary source.
Examples
• Meets NCQA standards for verification of education, residency and board certification • AMA profile:
https://profiles.ama-assn.org/amaprofiles/ AOA profile:
https://www.doprofiles.org/index.cfm
7/16/14&
6&
CVO
• “Credentials Verification Organization”
• CVO provides verification only!
• Maintains accreditation with NCQA (National Committee for Quality Assurance) or meet specific criteria determined by your Governing Body and accrediting body.
• Execute a written agreement that clearly delegates activities and the process
• Annually evaluate the services of the CVO
• Can use a healthcare organization that functions as a CVO
Verification vs. Document Copies
VERIFICATION ++
• Medical(License(
• DEA,(State(CDS(
• Hospital(Privileges(
• Education(and(Training(
• Board(Certification(
• Sanctions(
COPIES+
• Malpractice(Face(Sheet(
• Peer(References(
• BLS,(ACLS(
• TB(Test(
(
NPDB
• Facility must perform NPDB query
• http://www.npdb.hrsa.gov/hcorg/register.jsp
• NPDB established by Congress
• Information clearinghouse for issues with adverse licensure, privileging, Medicare/Medicaid exclusions, civil and criminal convictions, and medical malpractice payments
• Continuous Query(formerly Proactive Disclosure Service)
• Receive initial report and occurrences in next 12 months
7/16/14&
7&
DPM Credentials Verification
• License verification from State Board of Podiatric Medicine
• Education: National Student Clearing House http://www.studentclearinghouse.org/ or written request for podiatric college of American Podiatric Medical Association (APMA) if applicant is member
• Residency: Written request to Council on Podiatric Medical Education (CPME)
• Board Certification: Written request to American Board of Podiatric Orthopedics and Primary Podiatric Medicine (ABPOPPM) OR American Board of Podiatric Surgery
DDS Credential Verification
• License verification from State Dental Board
• Education: National Student Clearing House http://www.studentclearinghouse.org/ or written request to institution
• Residency: Written request to Institution
• Board Certification: Written request to the American Board of General Dentistry
Privileging
• Process of authorizing the specific scope of care a practitioner can perform at your ASC, based on their credentials and performance
• DOP must be completed
• DOP must be procedure specific
• Must include certain equipment (fluro interpretations)
• Must include supervision of non anesthesia personnel
• Must include anesthesia (i.e. local infiltrate)
7/16/14&
8&
Available on eSupport: Operations/Staffing/Privileges
Next Step
You now have: • A request for appointment, • a completed and verified
application, • and a DOP
Review Process
• MEC reviews the file contents and recommends granting, limiting or denial of privileges
• The Governing Body performs the final approval.
7/16/14&
9&
What to Review
• Does the information on the application match the verification?
• Are there lapses in work? If so, are there any additional items that should be asked?
• Are there any questions about malpractice cases settled against the practitioner?
• Have there been any issues related to suspension of license or other professional credentials
What to Review
• Do peer references demonstrate competence for new applicants?
• Does peer review demonstrate competence upon reappointments?
• Are any red flags raised on the NPDB query?
• For one owner/one practitioner ASCs, arrangements must be made for an outside peer to review the credentials and provide recommendations for privileges
After GB Approval
• Notify the practitioner, in writing of their appointment with a copy of the procedures approved
• Maintain current documentation for the entire appointment period
7/16/14&
10&
Reappointments
• Every 2 to 3 years
• Receive request from practitioner for reappointment
• Shortened application form, request for documents, and DOP
• No need to re-verify education or training
• Verify license, DEA, OIG, board certification
• MUST use peer review information
Available on eSupport: Operations/Staffing/Privileges
Peer Review
• Your GB should determine the type and amount of review conducted
• Random Chart Audits
• Specific criteria for each practitioner
• Incidents
7/16/14&
11&
Available on eSupport: Compliance/Policy and Procedure Update/QAPI
Credentialing non physicians
• Allied Health Professionals
• Physicians Assistant
• Nurse Practitioner
• RNFA
The Application
• Practitioner completes • Application • Liability Questionnaire • Release of Information • Peer Reference List • Health Statement • Signed statement attesting to the correctness
of the application • Delineation of privilege request form (DOP)
7/16/14&
12&
Submitted with Application
• State License(s)
• State CDS, if applicable
• DEA, if applicable
• Malpractice Face Sheet (practitioner name, policy number, amount of coverage per incident and aggregate, expiration date, name and address of insurance company)
Allied Health Supervision
• Require supervising physician • Supervising MD should be indicated (application
attestation, separate document)
• Require annual competency testing
• Require clearly outlined duties (job description or policy)
Available on eSupport: Operations/Staffing/Allied Health Professionals
7/16/14&
13&
CRNAs
• As of June 2014, 18 states are opt out states
• No supervision is required
• States may require certain parameters in oversight
• Credentialing via Medical Staff or AHP if independent?
• If supervision is required, complete annual competency
• Peer Review should be the same as MDA
State Specific
Check with your state and your accrediting body for specifics on CRNA Credentialing/Privileging requirements
Private Scrub Personnel
• Should obtain same information required for employees of the facility performing the same job
• Similar to personnel file with job description
OR
• Similar to medical staff/AHP file with DOP
• Orientation
• Evaluation and competency testing
7/16/14&
14&
Questions?
• Questions regarding todays content? • [email protected]
• Interested in subscribing to Progressive eSupport? • Visit www.progressivesurgicalsolutions.com/esupport
• Email us at [email protected]
• Or call us! (855) 777-4272
Mark your calendars!
Brought(to(you(by(
Join us next time for: Best Practices of Controlled Substances
Management (
Monday September 22, 2014 11AM PT/2PM ET
John Karwoski, RPh, MBA JDJ Consulting
(
