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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

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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

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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

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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

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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

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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

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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)

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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.

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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

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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

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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)

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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

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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

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Questions?

•  Questions regarding todays content? •  info@pss4asc.com

•  Interested in subscribing to Progressive eSupport? •  Visit www.progressivesurgicalsolutions.com/esupport

•  Email us at info@pss4asc.com

•  Or call us! (855) 777-4272

Mark your calendars!

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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

(