Presentation on theme: "IMPORTANCE OF CREDENTIALING"— Presentation transcript:
1 IMPORTANCE OF CREDENTIALING By: Anita Lambert-Gale, RN, MESExecutive Director of NursingUnited Surgical Partners International
2 Objectives Each participant will be able to: Identify major requirements of regulatory and accrediting bodies, for credentialingIdentify why credentialing is importantIdentify five (5) significant red flags in medical staff credentialing filesLeave with useful tools to facilitate the credentialing and recredentialing process
3 National IssuesFlorida: Fingerprints all medical license renewals - Discovered 2,000 out of 45,000 physicians have criminal records2001: nation’s medical boards took disciplinary action against 2,708 physiciansDEA fails to report 2,592 docs to NPDBMan poses as physician, spoke with and wrote a prescription for an ER patient.For 16 months, man posed as certified plastic surgeon; operated without medical degree, clinical training, license, or insurance. Today is on the run.
4 National Issues, Cont.Man assumes identity of a psychiatrist and practices for over 5 years.Maryland doc sued 18 times in 20 years with 9 suits resulting in payments of more than $20 million; Board ignored provision of state law that 3 or more claims in 5 years must be reported.
5 National Issues, Cont.2010 Surgeon at California hospital removed a healthy kidney (wrong site).The surgeon did not have privileges to perform procedure.Patient was non-English speakingPatient latter underwent procedure to remove the diseased kidney, leaving patient with no kidney.
6 National TrendsJuly 21, 2011 Gov. Pat Quinn signed into law in Illinois House Bill 1271Law mandates “immediate and permanent revocation” of licensure of healthcare professionals convicted of sex crimes, felony or patient battery.Immediately 11 healthcare professionals lost licensureJune 17, 2011 Gov. Rick Perry signed into law revocation of the medical license of any physician convicted of sexual assault or indecency with a child.
7 National TrendsSeptember 16, 2011 “Fake Doc Pleads Guilty in $1.2M Fraud Scheme”30 year old worked with licensed physicians and used their provider numbers to collect about $1.2 million in false claims with Medicare/Medicaid and private insurance companies.Was caught while trying to sell patient health information.
8 Importance of Credentialing “Credentialing is complex and exhaustive and requires a high degree of management to assure the proper completion of documentation and follow through with all parties involved in the process.” From Patrick Birmingham, head of EnrollMed Operation of Medkinetics.com
9 Purpose of Credentialing To assure that only qualified practitioners who can demonstrate current clinical competence are granted clinical privileges
10 Reasons to CredentialRequired by State and Regulatory Agencies, i.e. State, TJC, AAAHC CMS, OIGTo assist in the risk management of the Facility/CenterTo “go the extra mile” to ensure those providing the healthcare services to our patients are competent and qualified.
11 Appointment/Reappointment Credentialing for appointment ensures the physician has the training and education to provide services.Reappointment ensures the physician continues or increases knowledge base to provide care.
13 Darling v. Charleston Community Mem. Hospital, 211 N. E. 2d 253 (Ill Darling v. Charleston Community Mem. Hospital, 211 N.E. 2d 253 (Ill. 1965) cert. Denied, 383 U.S. 946 (1966)1st case to hold that hospitals have a corporate duty to monitor patient care being provided in the facility.Employees must observe condition of patients and report findings to higher authority if attending physician does not do what is clearly proper.Hospital found liable for negligent treatment of patient by physician.2
14 Bell v. Sharp Cabrillo Hospital, 212 Cal. Appropriate 3d 1034, 260 Cal Bell v. Sharp Cabrillo Hospital, 212 Cal. Appropriate 3d 1034, 260 Cal. Rptr. 886 (Ca. 1989)Negligence in reappointment; Negligent credentialing.Hospital liable for physician’s actions due to its failure to request data from other hospital about basis for its summary suspension. No deficiencies had occurred at Sharp Cabrillo.
15 Elam v. College Park Hospital, 132 Cal. Appropriate. 332, 183 Cal. Rptr. 156 (Ca. 1982) Negligent CredentialingHospital liable for podiatrist’s negligence; failed to obtain malpractice claims data; although medical records department aware of claims.Court held that a hospital has a duty to both select and review staff physicians adequately.
16 Johnson v. Misericordia Community Hospital, 294 N. W. 2d 501, 97 Wis Johnson v. Misericordia Community Hospital, 294 N.W. 2d 501, 97 Wis. 2d 521 (Wis. 1981)Negligent credentialing; Failure of Initial Credentialing ProcessHospital liable for patient injured by physician who failed to disclose pending malpractice cases and lied about privileges at other hospitals; should have verified information.Court ruled the hospital had contributed to the patient’s injury simply by allowing the physician to have staff privileges.
17 Where to Begin Medical Staff Bylaws Medical Staff Rules & Regulations Credentialing Policies & Procedures
18 Medical Staff Bylaws Very Important document. Must be consistent with applicable licensing, certifying and accrediting bodies.
19 Medical Staff Bylaws Components DefinitionsPurpose and ResponsibilitiesMedical Staff membershipCategories of the Medical StaffAllied Health ProfessionalMedical Staff Clinical PrivilegesCorrective Actions
20 Components, Cont. Hearing and Appellate Review Procedures Officers of the Medical StaffCommittees and FunctionsMeetingsConfidentiality & Immunity from LiabilityAmendments & Adoptions of Bylaws
21 Medical Staff Rules & Regulations Should be consistent with the BylawsUsually will embody the specific standards and level of practice that are required of each memberMay be thought of as the Medical Staff’s policies and procedures
22 Credentialing Policies & Procedures Should carefully define the steps in the credentialing and privileging processShould be carefully followed, not to do so places the facility at great risk
23 CredentialingIssue to applicant cover letter, delineated privilege list and a copy of the Medical Staff Bylaws and Rules & Regulations
24 Credentialing -Verify *Initial granting, verifies by viewing a valid government issues photo ID issued by a state or federal agencyCurrent licensureCurrent DEARelevant Education/TrainingHospital AffiliationsBoard CertificationAbility to Perform Requested PrivilegesMalpractice Insurance (with applicable limits)
25 Credentialing Malpractice Claims History Query National Practitioner Data BankCriminal Background Check (per your Bylaws)Peer References
27 Red Flags for Initial Appointment Incomplete areas on the ApplicationUnexplained time gaps in training and/or practicePositive responses regarding loss of privileges or restrictions or loss of licensure/DEA registrationFrequent changes in location in a short period of timePending/settled lawsuits - two fold issueNon-responses from referencesCancellation notice from Malpractice carrier received during or after processNegative information from State Licensure Association
28 CMS CfCsRequire that Clinical Privileges be granted by the Governing BodyEnsure that this is the language in your Medical Staff Bylaws, Rules & Regulations, and any policies.Especially temporary privileges.
29 Clinical PrivilegesReview all clinical privileges in light of what you actually do at your facility.Delete any privileges on the that you do not perform.Add any additional privileges that you do in your facility for that specific specialtyTJC requires NPDB with addition of privileges.DOPs MUST match facility’s approved procedures list
30 Clinical PrivilegesSedation by Non-anesthesiologist should be specifically privilegedMedical Staff Leadership (MEC) must determine criteria to be utilized for granting Sedation privileges (Review community standard)Verify that the physician meets the criteriaSuggest privileges specify age groups for proceduresSuggest privileges for EKG & radiology interpretation, as appropriate
31 Clinical Privileges§416.42(c) “The ASC must specify the anesthesia privileges for each practitioner who administers anesthesia, or who supervise the administration of anesthesia by another practitioner. The privileges granted must be in accordance with state law and the ASC’s policy. The type and complexity of procedures for which the practitioner may administer anesthesia or supervise another practitioner supervising anesthesia, must be specified in privileges granted to the individual practitioner.”
32 Clinical Privileges§416.42(c) “when an ASC permits operating physicians to supervising CRNA’s administering anesthesia, the governing body must adopt written policies that explicitly provide for this.
33 Clinical PrivilegesMust make sure that all applicable boxes are checkedMust have documented current competency for the requested privileges
34 Request for Additional Procedures FORM TO REQUEST ADDITION OF A PROCEDURE TO THE APPROVED PROCEDURE LIST.Identify the Procedure:____________________The usual age range for the patients undergoing this procedure: ___________________Additional Equipment Needed:_______________Type of Anesthesia Required: ______________Projected OR Time: ___ Projected PACU Time: _Any other information that may assist the MAC and BOG in their decision:_____________Requesting Physician: _________ Date:________
35 Educational Commission for Foreign Medical Graduates (ECFMG) If physician has ECFMG number, you must directly query the ECFMG to verify. AMA Profile is NOT primary source for ECFMG.You may establish an account with ECFMG for on line verificationOr ECFMG sends out monthly invoice to facility at $25 per inquiry.Each facility must have separate organization number - if new, state new vendor and number will be assigned to you on report.ECFMG is primary source for foreign medical school per Joint Commission.
36 Primary Source Verification What is it?How do you do it?What needs to be verified via Primary Source?
37 Reappointment Review Utilize the AMA reappointment profile Be sure to include information regarding performance at the facility.
38 When do Privileges Change? When a physician receives additional education, he/she may apply for amended privileges.When the facility adds additional programs which will require new privileges.When the facility revises existing programs and privileges are no longer needed/utilized.At time of reappointment.
39 Initial Appointment Success Start with a complete application.Follow the credentialing policies and proceduresUse your checklistSend out letters within 10 days of receipt of applicationSend follow-up letters within 30 daysRequest the assistance of the practitioner if you are having difficulty getting responses
40 Perform Verifications On-line National Practitioner Data BankState Licensing BoardDEA & if applicable State SpecificAMA Profiles (American Medical Association)OIG Sanctions (Office of Inspector General)GSA (Exclusions)Criminal backgroundSome Healthcare System have on-line verification for Medical Staff Membership and Privileges
41 More Tools Telephone verifications Fax verifications Feel as though you’ve been asked to pull a rabbit out of a hat?Telephone verificationscomplete appropriate telephone verification form and sign/dateFax verificationssign/date faxes receivedUse Outlook to create tickler file (reminders for follow-up letters)
42 ReappointmentsThe reappointment process focuses on the practitioner’s professional behavior and competence while functioning at the institutionTime frames vary, usually every two years (refer to state regulations, TJC every 2 years, AAAHC every 3 years)Reappointment standard is surfacing as one of the most problematic standards for facilities - greater survey focus
43 How to Combat Reappointment Delays Keys to Success - thorough planning and follow throughUse the data base to review the number of reappointments scheduled to be processed within a particular quarter and plan your time accordingly
44 Combating Delays, Cont. Take a proactive approach Send reappointment materials to physicians 4-5 months prior to expiration of privilegesSend materials registered mail (Common obstacle to timely reapplication completion is a physician’s failure to return his or her reappointment materials)Follow-up with reminder letters or telephone calls
45 Combating Delays, Cont.Quality Data - (Internal information gathered intoprovider profile)Volume, medical record completion and clinical pertinence, risk management, results of peer review, patient and staff complaints, aggregate performance data, (medical assessment and treatment of patients, blood, drug, operative/invasive procedures, UR, departures from established patterns of clinical practice, compliance with bylaws/rules and regs/policies, and meeting attendanceMissed the deadline?Inform LIP he/she would be required to cease providing care in the facility until the reappointment process is completed
46 Credentialing Elements Not Required on Reappointment Medical Education, Internships, Residencies and Fellowships - these elements are considered static, and therefore do not need to be reverified
47 State Medical License Most states now have an online service Follow up on any indication there is something confidential or adverseRead the material thoroughly!
48 SanctionsCheck web site for OIG or GSA sanctions at appointment and reappointment.If physician has been sanctioned and on your staff and are seeing patients, you could potentially lose reimbursement on patients seen by physician.Statement that there is “no report” is what you want to obtain
49 NPDBSuggestion - Have any adverse information initialed by Medical Director as evidence that this was considered in the appointment/ reappointment process.
50 Miscellaneous Websites - major site for credentialing information - also provide free weekly newsletter via ; sign up at web site- National Association of Medical Staff Services
51 Temporary Privileges Must be provided for within your Bylaws Must follow your Bylaws
52 Verify the following: For important patient needs: Current licensure Current competenceBoth of these can be accomplished by a phone call.
53 Verify the following: New Applicants Current licensure Relevant education training or experienceCurrent competencyAbility to perform the privileges requestedNPDBCriteria identified in the bylaws, rules & regs
54 Temporary Privileges New applicants must have the following A complete applicationNo current or previously successful challenge to licensure or registrationNot been subject to involuntary limitation, reduction, denial, or loss of privileges, when applicable to discipline
55 Who can grant these temporary privileges? Joint Commission states the “Administrator or designee grants temporary privileges for meeting important patient needs and for new applicants upon the recommendation of clinical leadership or the medical director.”
56 Temporary PrivilegesWhen an applicant with a complete, clean application is waiting for review by the MEC and Governing Body:Must have verified current licensure, relevant training or experience, current competence, ability to perform privileges requestedMust have queried NPDBand evaluated report
57 Temporary PrivilegesWhen an applicant has a complete application:No current or previously successful challenge to licensure or registrationNot been subject to involuntary termination of medical staff membership at another organizationNot been subject to involuntary limitation, reduction, denial or loss of clinical privileges.
58 When You Should Not Use Temporary Privileges. LIP fails to provide necessary information in a timely manner.Facility fails to verify necessary information in a timely manner.
59 Temporary Privileges and NPDB Any time a physician surrenders his privileges (temporary or not) while under investigation, this is reportable to the NPDB. Grant temporary privileges before joining staff, start an investigation and temporary privileges have to be revoked, withdrawn, etc, and become reportable to the data bank.
60 CVOs Credentials Verification Organizations Joint Commission defines as any organization that provides information on an individual’s professional credentials.Further the organization should have confidence in the completeness, accuracy, and timeliness of the informationJoint Commission identifies 10 principles to guide a CVO organization.
61 10 Principles for CVOs1. Makes known to the user the data and information it can provide.Provides documentation to the user describing how its data collection, information development, and verification process(es) are performed.
62 10 Principles (cont)3. Provides sufficient, clear information on database functions, including any limitations of information available from the agency (such as practitioners not included in the database), the time frame for agency responses to requests for information, and a summary overview of quality control processes related to data integrity, security, transmission accuracy, and technical specifications.
63 10 Principles (cont)Both agree on the format for transmitting information about an individual.User can easily discern what information transmitted by the CVO is from primary source and what is not.For information transmitted by the agency that can go out of date, the CVO provides the date information was last updated from the primary source.
64 10 Principles (cont)CVO certifies that the information transmitted to the user accurately represents the information obtained by it.User can discern whether the information transmitted by the CVO from a primary source is all primary source information in the CVO’s possession pertinent to a given item or, if not, where additional information can be obtained.
65 10 Principles (cont)User can engage the CVO’s quality control processes when necessary to resolve concerns about transmission errors, inconsistencies, or other data issues that may be identified.User has a formal arrangement with the CVO for communicating changes in credentialing information.
66 AAAHC’s CVO Standards“An accreditable organization may use information provided by a CVO after proper assessment of the capabilities and quality of the CVO…a CVO may demonstrate such capability and quality by becoming accredited or certified by a nationally recognized accreditation organization. Primary or secondary source verification is required for items listed
67 AAAHC’s CVO Standards (cont) 9In manual), unless a CVO or an organization performing primary source verification that is accredited or certified by a nationally recognized body is used. If the organization utilizes a CVO or another organization to verify credentials, those entities must perform primary source verification unless such sources do not exist or are impossible to verify.”
68 Problematic AreaTops the of list of problematic standards from virtually all accrediting bodies
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