Credentialing & Privileging What Executives Should Know May 12, 2015

Credentialing & Privileging What Executives Should Know May 12, 2015
Karen Beem, MS, RN Standards Interpretation

Credentialing & Privileging
Objectives Upon completion of this presentation, the participant will: Discuss five (5) responsibilities of the Governing Body that are relevant to medical staff credentialing and privileging. List ten (10) “Red Flags” that require investigation during review of applications for appointment to the medical staff. List four (4) non-physician practitioners that may be granted privileges, consistent with State law, Medical Staff and Governing Body. May 12, 2015 Credentialing & Privileging

Objectives Describe the new CMS guidelines regarding the flexibility of hospitals to allow non-members of the medical staff to write orders for outpatient services. May 12, 2015 Credentialing & Privileging

Definition Credentialing: The process of verifying the qualifications of the professional to ensure current competence by assessing: Educational and training background Work history Current licensure References, and Ability to perform the services / privileges requested. May 12, 2015 Credentialing & Privileging

Definition Privileges: The specific patient care diagnostic or therapeutic procedures a physician or non-physician practitioner is permitted to perform in a specific facility. Based on evaluation of the individual, the medical staff prepares recommendations to grant, deny, continue, revise, discontinue, limit, or revoke privileges, to the governing body. Only the Governing Body has the authority to grant: Clinical privileges, after reviewing medical staff recommendations and / or Medical Staff membership May 12, 2015 Credentialing & Privileging

Definition Primary Source Verification (PSV): The verification of information directly from the original source. Primary source verification is required to verify the accuracy of education, training, licensure, exams, and board certification information. May 12, 2015 Credentialing & Privileging

Definition Non-Physician Practitioner: Former terms: Midlevel Practitioner or Allied Health Practitioner Non-Physician Practitioner (NPP) includes, but not limited to: Nurse Practitioner Physician Assistant Clinical Nurse Specialist Certified Nurse Anesthesiologist Certified Nurse Midwife Clinical Social Worker Clinical Psychologist Anesthesiologist Assistant May 12, 2015 Credentialing & Privileging

Definition Appointment and Re-appointment: Initial Appointment: The first appointment to the medical staff. Appointments may be no longer than 2 years, but may be less. Re-appointment: The medical staff must periodically re-appraise all professionals appointed to the medical staff / granted medical staff privileges to determine current competence. Purpose of appraisal: To determine suitability of continuing the medical staff membership or privileges. Reappraisal is to be conducted at least every 24 months. Without renewal, practitioner is practicing without privileges (expired privileges). The medical staff appraisal procedures must evaluate each individual practitioner’s qualifications and demonstrated competencies to perform task / privileges. May 12, 2015 Credentialing & Privileging

Definition “Complete” Application: Elements of a Complete Application: The candidate has answered all questions on the application form(s) The candidate has provided all requested documents Three (3) or more letters of recommendation have been received Information has undergone Primary Source Verification Fees have been paid An incomplete application for membership / request for privileges cannot be submitted for consideration. Temporary privileges may not be granted May not begin to see patients May 12, 2015 Credentialing & Privileging

Responsibilities of the Governing Body
May 12, 2015 Credentialing & Privileging

The Governing Body Is legally responsible for the conduct of the hospital and the care provided. (Standard ) Must determine which categories of practitioners are eligible candidates for appointment to the medical staff. (Standard ) Must appoint members of the medical staff after considering the recommendations of the medical staff. (Standard ) Must approve the medical staff bylaws and other medical staff rules and regulations (including changes). (Standard ) May 12, 2015 Credentialing & Privileging

The Governing Body Has the authority to make final decisions regarding appointment and granting of privileges. (Standard ) Consistent with medical staff criteria, State and Federal regulations, determines whether to: Grant, Deny, Continue, Revise, Discontinue, Limit or Revoke privileges including medical staff membership May 12, 2015 Credentialing & Privileging

Why Is It Important for Executives to Understand the Credentialing & Privileging Process? May 12, 2015 Credentialing & Privileging

Negligent Credentialing
Plaintiff Must Prove: Hospital failed to exercise reasonable care in granting medical staff privileges or membership to a physician; The physician that was negligently credentialed breached the standard of care when treating the plaintiff; and The negligent credentialing of the negligent physician was a proximate cause of the plaintiff's injuries May 12, 2015 Credentialing & Privileging

Cases of Negligent Credentialing
Johnson v. Misericordia False information & omitted information on the application Hospital did not verify the information Frigo v. Silver Cross Hospital (2007) ($7,775,688) Physician did not initially meet eligibility requirements Reappointed without meeting eligibility requirements Kadlec v. Lakeview Anesthesia Assoc. and Lakeview Medical Center Peer references provided misleading information May 12, 2015 Credentialing & Privileging

Minimize Risk Regular Training: Medical Staff Office personnel Medical Staff Department Chairs Medical Staff Officers Members Medical Executive Committee Credentials Committee Members, Governing Body May 12, 2015 Credentialing & Privileging

Minimize Risk Policies: Bylaws, Rules & Regs, and medical staff policies Understand Bylaws and policies Consistent application of Bylaws and policies Update Bylaws and policies May 12, 2015 Credentialing & Privileging

Audit Bylaws to Determine Gaps
Ensure Bylaws are current and consistent with State, Federal, and accreditation requirements Are the Medical Staff Bylaws consistent with Governing Body Bylaws? Are members of the medical staff required to comply with “Code of Conduct / Disruptive Behavior” policy? May 12, 2015 Credentialing & Privileging

Do the Bylaws Address? Requirement to Report to the Medical Staff: Within 5 days - Insurance coverage reduced below required limits Felony convictions Medicare/Medicaid sanctions Loss of privileges Loss of license Malpractice suits within established timelines May 12, 2015 Credentialing & Privileging

Do the Bylaws Address? On-call Requirements: Expected response time Responsibility to identify the back-up physician Person with same privileges Person agreed to serve as back-up for the dates specified Physician responsibility to provide post-ED follow-up treatment May 12, 2015 Credentialing & Privileging

Do the Bylaws Address? Medical Record Documentation Expectations: History & Physical within 30 days Written Updated Examination to the History & Physical: Within 24 hours of admission Prior to anesthesia Discharge Summary Authentication of verbal orders May 12, 2015 Credentialing & Privileging

Do the Bylaws Address? Requirements to Query the NPDB: When Medical Staff will Query: Initial Appointment Request for NEW Privileges Re-appointment Whom the Medical Staff will Query: Physicians and Dentists Non-physician practitioners Locum Tenens Requests for Temporary Privileges May 12, 2015 Credentialing & Privileging

Do the Bylaws Address? What the Medical Staff will Report to NPDB Denials or restrictions of clinical privileges for more than 30 days that result from professional review actions relating to the practitioner’s professional competence or professional conduct that adversely affects, or could adversely affect, the health or welfare of a patient May 12, 2015 Credentialing & Privileging

Responsibility of the Governing Body: Competent Practitioners

Eligibility for Appointment
All practitioners who require privileges in order to furnish care to hospital patients: Must be evaluated under the hospital’s medical staff privileging system Before the governing body may grant privileges. Includes physicians and non-physician practitioners granted privileges. (see ) May 12, 2015 Credentialing & Privileging

Duty of the Organization
The hospital is responsible to grant privileges only to competent practitioners. May 12, 2015 Credentialing & Privileging

Application Process May 12, 2015 Credentialing & Privileging

Pre-Application Purpose: To screen applicants for basic eligibility. Denial of a Pre-Application is NOT reportable to NPDB. May 12, 2015 Credentialing & Privileging

Pre-Application Packet
Medical Staff with Legal Counsel Determine Materials: Eligibility Requirements to Receive Full Application Distance Requirements: Home and Office Current license in the State where the patient will be treated Applicant to sign an “Absolute Release and Waiver of Liability” Form Affiliation with Competitor: Are you now or have you been employed by a competitor or have financial interest in a competitor? Are you now or have you been a member of the medical staff leadership at a competing hospital, ASC, or entity? May 12, 2015 Credentialing & Privileging

Decision to Send Full Application
Consistent application per policy Application Materials: State Mandated Application form Hospital-specific Application form Request for Privileges Medical Staff Bylaws, Governing Body Bylaws and Rules & Regulations, relevant Medical Staff Policies, etc. May 12, 2015 Credentialing & Privileging

Application Packet Request List of Professional References Applicant to sign affidavit: “Information provided is current and accurate.” This cannot be delegated May 12, 2015 Credentialing & Privileging

Begin Processing Application
Upon receipt of the signed Absolute Waiver: Hospital sends requests for references: Attach copy of the signed Absolute Waiver Attach copy of government-issued photo; verify individual Acceptable to send electronic request for references Reduces delays with response Auto-resend Medical Staff Office begins data collection and verification Individual Credentials File Application Checklist May 12, 2015 Credentialing & Privileging

Evaluation of Application
Key elements to identify during review process Red Flags Red flags do not automatically preclude a practitioner from the medical staff. These trigger the need for investigation of the circumstances. May 12, 2015 Credentialing & Privileging

Red Flags The Applicant: Submits an incomplete application Changed medical schools or residency programs or gaps in training Unexplained / unaccounted time gaps in education / employment. Practiced or licensed in 3 or more states Changed practice locations more than 3 times in 10 years Why incomplete? Prepared in haste? Lacks attention to detail? Avoiding something? Change location = caution. May want to place a telephone call for additional information. May 12, 2015 Credentialing & Privileging

Red Flags Inability to maintain a medical practice in the facility’s service area. Resignation from a medical staff at any time in career. Reports of problems in an applicant’s professional practice. One or more references that raise concerns or questions, e.g., “Please call for information.” No response to a reference inquiry from an applicant’s past affiliation. 10: No response = place a call. Perhaps this request has been legitimately misplaced. Perhaps, the other person is reluctant to put concerns into writing. May 12, 2015 Credentialing & Privileging

Red Flags Disciplinary actions by medical staff organizations, hospitals, state medical boards, or professional societies. Any past or pending state licensing board, medical staff organization, or professional society investigative proceedings. Any claims or investigations of fraud, abuse and/or misconduct from professional review organizations, third-party payers, or government entities. Little or no verified coverage from a professional liability insurance policy. May 12, 2015 Credentialing & Privileging

Red Flags Jury verdicts and settlements for professional liability claims. Any discrepancies identified between: Application Primary Source Verification information References May 12, 2015 Credentialing & Privileging

Application Verification: Licensure
Licensure History: Initial Appointment: Primary Source Verification Licensure, registration, and certification history Must be licensed in state where patients are located Check all licenses (current and previous) and any previous healthcare disciplines, e.g., NP, PA Lifetime history preferred Check for sanctions Reappointment Any licenses surrendered since last appointment? May 12, 2015 Credentialing & Privileging

Application Verification: Licensure
Primary Source Verification State Licensing Boards, FSMB Any sanctions? DEA Registration: DEA controlled-substance registration actions Query the NPDB Medical malpractice payments OIG Exclusions from Medicare and Medicaid Adverse licensure actions related to professional competence or conduct May 12, 2015 Credentialing & Privileging

Application Verification: Education
Medical Education & Post-Graduate Training: Initial Appointment: Request lifetime clinical education and training history: medical, osteopathic, podiatric, dental, residency and fellowship programs Require for each program: Start Date and End Date Explain any gaps > 90 days May 12, 2015 Credentialing & Privileging

Application Verification: Education
Re-appointment: N/A Request for New Privileges: Request education and training Primary Source Verification: National Student Clearinghouse, AMA, AOA, ECFMG, and applicable professional schools or residency training programs. May 12, 2015 Credentialing & Privileging

Application Verification: Insurance
Medical Malpractice Insurance History: Initial Appointment Open & pending cases, claims, lawsuits, settlements, judgements, and dismissed cases Minimum: 5 year malpractice history Best Practice: 10 year history of claims Appropriate coverage for the requested privilege? Reappointment Pending cases, claims, lawsuits, settlements, judgements for past 2 years May 12, 2015 Credentialing & Privileging

Request Former Malpractice Insurance policies (past 5 years) Policy number Current Certificates of Insurance: Determine Limits and exclusions Per occurrence? Current Coverage Schedule: Determine Apply to multiple hospitals if claims are made? Apply to multiple members of a group? Coverage if depleted by others in the group? May 12, 2015 Credentialing & Privileging

Legal Counsel to Advise Interpretation of the Coverage Schedule Benefits of requiring a tail for prior acts coverage Verify Insurance Company Rating Consistent with Governing Body Listing, e.g., Standard and Poor’s or AM Best Legal Counsel to advise regarding low rated companies Primary Source Verification Current and Past Malpractice Carriers NPDB May 12, 2015 Credentialing & Privileging

Application Verification: Boards
Specialty Board Certification Status: Initial Appointment Board Status: None or current certification Eligible to take exam? When? Components taken? Passed? Failed? Number of times exam was taken? Reappointment Consistent application of policies Monitor completion of exams Compliance with Maintenance of Certification (MOC) May 12, 2015 Credentialing & Privileging

Application Verification: Sanctions
Sanctions or Disciplinary Actions: Initial Appointment & Reappointment Disciplinary actions taken or investigations pending by hospitals or other healthcare facilities, specialty boards, Medicare / Medicaid; Actions against the Federal Drug Enforcement Agency (DEA) certificate or State Controlled Dangerous Substances (CDS) certificate; and Actions listed in the National Practitioner Data Bank (NPDB). May 12, 2015 Credentialing & Privileging

Application Verification: Sanctions
Primary Source Verification: NPDB, FSMB, and OIG List of Excluded Individuals/Entities (LEIE) monthly Hospital Responsibility: To investigate all sanctions or disciplinary actions Consistent application of Bylaws / policies Document findings, discussions, and actions taken to resolve May 12, 2015 Credentialing & Privileging

Application Verification: Criminal
Criminal History: Initial Appointment Minimum: 7 – 10 years; Lifetime history preferred Investigate: Information provided in the application or as required by federal and state regulations. Reappointment As required by federal and state regulations. May 12, 2015 Credentialing & Privileging

Application Verification: Criminal
Primary Source Verification: Federal, State, and County Databases Each county in which applicant resided and worked Finger printing: Optional State vs. Nationwide Fee for service Investigate findings May 12, 2015 Credentialing & Privileging

Application Verification: Employment
Healthcare Employment History: Initial Appointment & Reappointment Healthcare Employment: To provide a chronological, comprehensive listing of each facility where clinical privileges were held Start Date and End Date Explain gaps Primary Source Verification: Dates Verify: Left in good standing May 12, 2015 Credentialing & Privileging

Application Verification: Employment
Investigate: Gaps in employment Did not leave in “good standing” Terminations, challenges, pending investigations and decisions, voluntary resignations, and relinquishments of membership or privileges Termination or non-renewal of employment contracts May 12, 2015 Credentialing & Privileging

Application Verification: References
Professional References: Initial Appointment Purpose: Determine current competence, ability to perform requested privileges, and peer recommendations Attach: Copy of a government-issued photo when sending requests for reference; ask for verification of individual Current list of privileges Reappointment Letters of reference are not required OPPE and peer review will suffice May 12, 2015 Credentialing & Privileging

Application Verification: References
Professional References Professional authorities who have worked with applicant in past 2 years Can authoritatively speak to experience and competence Able to address current competencies (provide tool and list of privileges) Selection of Peer References Within the same discipline; preferably, not a partner At least one (1) physician for NP and PA May 12, 2015 Credentialing & Privileging

Application Verification: Activity
Clinical Activity: Initial Appointment Request 6 – 24 month summary (numbers and type of procedures / conditions) Activity logs to Support Requested Privileges: Submit from Residency / Fellowship programs Former / other affiliates Current Competence OPPE report from former / other affiliates May 12, 2015 Credentialing & Privileging

Application Verification: Activity
Clinical Activity – Submit Procedure Logs: Reappointment – Activity for past 2 years Obtain current facility procedure report Low / no volume: Request reports from external source, consistent with policy May 12, 2015 Credentialing & Privileging

Credentialing and Privileging Process
Review of Applications: Consistent application of policy Incomplete applications may not be forwarded for review Medical Staff policy defines time limits for application completion Summary of Red Flags Document findings, discussions, and actions. May 12, 2015 Credentialing & Privileging

Credentialing and Privileging Process
The Completed Application is submitted to: Chair, respective Medical Department Credentials Committee: Prepares recommendations for privileges Medical Executive Committee: Prepares recommendations for privileges Governing Body: Reviews Medical Staff recommendations; grants / denies / revises privileges Applicant is notified of the Governing Body’s decision Begin: FPPE and OPPE May 12, 2015 Credentialing & Privileging

The Governing Body Meeting Minutes to Reflect
“At the recommendation of the Medical Staff…” “The Governing Body grants to (NAME) the following privileges ….” Effective date of the privileges and expiration date, e.g., Effective at Midnight, May 1, 2015 Expires at 11:59 pm, April 30, 2017 May 12, 2015 Credentialing & Privileging

Multi-hospital Health Systems
Privileges may only be granted for procedures offered at the hospital: Memorial Medical Center: Offers a comprehensive neurosurgery service Community Hospital: No neurosurgery Cannot grant neurosurgical privileges The Governing Body meeting minutes must reflect the privileges granted to each practitioner for each hospital May 12, 2015 Credentialing & Privileging

Is credentialing and privileging required for physicians and non-physician practitioners working in an ambulatory settings? Answer: Yes, if the ambulatory setting bills for services using the hospital CCN (Medicare Provider Number). This is considered to be a department of the hospital. May 12, 2015 Credentialing & Privileging

Is credentialing and privileging required for physicians and non-physician practitioners who are employees of the hospital? Answer: Yes, all practitioners who require privileges in order to furnish care to hospital patients must be evaluated under the hospital’s medical staff privileging system before the hospital’s governing body may grant them privileges. (Standard ) May 12, 2015 Credentialing & Privileging

Is credentialing and privileging required for telemedicine practitioners? Answer: Full details: See standards ; ; ; and The credentialing may be performed onsite or at distant hospital / entity. Be sure the medical staff makes recommendations to the governing body. Ensure the governing body grants the privileges. May 12, 2015 Credentialing & Privileging

Temporary Privileges Must be infrequently granted A “Completed application” is required Review with recommendations for privileges by: Chief of Staff / Department Chair CEO Process: Is the Governing Body meeting scheduled too proximal to the expiration of privileges to avoid: Holidays & inclement weather May 12, 2015 Credentialing & Privileging

Locum Tenens Consistent application of Bylaws and policies A “Completed application” is required Review with recommendations by: Chief of Staff / Department Chair CEO Process: Has the Medical Staff and the Governing Body established procedures to reduce “last minute” requests? May 12, 2015 Credentialing & Privileging

Governing Body Responsibility: Determine Categories Eligible for Appointment May 12, 2015 Credentialing & Privileging

Categories Eligible for Appointment
The governing body must determine, in accordance with State law, which categories of practitioners are eligible candidates for appointment to the medical staff (Standard ) Non-physician Practitioners: The governing body has the authority, in accordance with State law, To grant medical staff privileges and membership to non- physician practitioners. Granting medical staff privileges and membership to non-physician practitioners is an option available to the governing body; it is not a requirement. May 12, 2015 Credentialing & Privileging

CMS Update: Privileges to Write Orders for Services
Services must be ordered by a qualified and licensed practitioner who is responsible for the care of the patient. Must have medical staff privileges to write orders for these services. Such privileges must be granted consistent with the State’s scope of practice law, hospital policies and procedures, developed by the medical staff and approved by the governing body and may include: Nurse Practitioners Physicians’ Assistants Clinical Nurse Specialists Others consistent with State scope of practice, medical staff, and governing body policies May 12, 2015 Credentialing & Privileging

CMS Update: Orders for Services
Hospitals have flexibility to grant privileges to write orders: Respiratory Care Services Standard Services Provided §482.57(b)(3) Rehabilitation Services Standard Services Provided §482.56(b) Diet Orders: Therapeutic Diets & Supplements Standard Diet Orders §482.28(b)(2) May 12, 2015 Credentialing & Privileging

Non-Physician Practitioners
Eligible for Privileges New: Option to Privilege Nurse Practitioner Physician Assistant Clinical Nurse Specialist Certified Nurse Anesthesiologist Certified Nurse Midwife Clinical Social Worker Clinical Psychologist Anesthesiologist Assistant Physical Therapists Occupational Therapists Speech Language Therapists Qualified Dietitians / Nutritionists Certain Licensed Pharmacists May 12, 2015 Credentialing & Privileging

State Law & Scope of Practice
Privileges to Write Orders: Governing body, when permitted by State law and upon recommendation of the medical staff, may grant privileges Hospital is responsible to ensure the individual is qualified under State law before appointing to the medical staff or granting privileges. May 12, 2015 Credentialing & Privileging

Periodic Appraisal of Members
The Medical Staff must periodically appraise its members. At regular intervals, the medical staff must appraise the qualifications of all practitioners including non-physician practitioners. To determine competency and suitability for continuing privileges The OPPE / FPPE process for all practitioners with privileges At least every 24 months (See ) May 12, 2015 Credentialing & Privileging

Practitioners Granted Privileges Only
The governing body and medical staff must exercise oversight: Through credentialing Competency review (OPPE / FPPE) of those practitioners to whom it grants privileges, Just as it would for those practitioners appointed to its medical staff. (Standard ) May 12, 2015 Credentialing & Privileging

CMS Update: Outpatient Services

31.00.11 Orders for Outpatient Services
Services must be ordered by a practitioner who: Is responsible for the care of the patient. Is licensed in the State where he or she provides care to the patient. Is acting within his or her scope of practice under State law. Is authorized in accordance with State law and policies adopted by the medical staff, and approved by the governing body, to order the applicable outpatient services. May 12, 2015 Credentialing & Privileging

Orders for Outpatient Services
Hospital Policy: For practitioners who do not hold hospital privileges the hospital’s medical staff policy may permit them to refer patients to the hospital with orders for specific outpatient services If all of the above 4 criteria are met. May 12, 2015 Credentialing & Privileging

Policy Must Address: How the hospital verifies the referring/ordering practitioner is appropriately licensed and acting within his/her scope of practice. The regulation does not prescribe the details of the licensure and scope of practice verification process but instead provides a hospital the flexibility to accomplish this in the manner it finds efficient and effective. The hospital is expected to ensure the verification process is followed for all outpatient services in all hospital locations. May 12, 2015 Credentialing & Privileging

Policy Must Also: Make clear whether the policy applies to all hospital outpatient services, or Whether there are specific services for which orders may only be accepted from practitioners with medical staff privileges. Example: A hospital prefers to not accept orders for a regimen of outpatient chemotherapy or outpatient therapeutic nuclear medicine services from a physician without privileges. Policy must make these exceptions clear to the general authorization for accepting orders from referring practitioners. May 12, 2015 Credentialing & Privileging

National Practitioner Data Bank

NPDB Guidelines April 6, 2015 National Practitioner Data Bank
U.S. Department of Health and Human Services Clearinghouse: To improve the quality of medical care. To restrict incompetent physicians and dentists from moving from State to State without disclosure or discovery of previous damaging or incompetent performance. 2013: Consolidated NPDB and HIPDB to eliminate duplication. May 12, 2015 Credentialing & Privileging

Must Report to NPDB Adverse Clinical Privilege Actions
Any professional review action that adversely affects the clinical privileges of a physician or dentist for a period of more than 30 days, or The acceptance of the surrender of clinical privileges, or any restriction of such privileges by a physician or dentist, While the physician or dentist is under investigation by a health care entity relating to possible incompetence or improper professional conduct, or In return for not conducting such an investigation or proceeding. May 12, 2015 Credentialing & Privileging

Must Report to NPDB Denials or Restrictions: Based on Professional Review Actions relating to professional competence or conduct that adversely affects, or could adversely affect, the health or welfare of a patient Voluntary Withdrawal: If a practitioner applies for renewal of a medical staff appointment or clinical privileges and voluntarily withdraws that application while under investigation or possible professional incompetence or improper professional conduct or in return for not conducting such an investigation or not taking a professional review action Non-renewals: While under investigation by the health care entity for possible professional incompetence or improper professional conduct May 12, 2015 Credentialing & Privileging

Must Report to NPDB Summary Suspensions: If imposed for more than 30 days Based on professional competence or professional conduct Result of professional review action Proctors: If, as a result of professional review action r/t professional competence or conduct, a proctor is assigned for a period >30 days… If, for a period lasting more than 30 days, the physician or dentist cannot perform certain procedures without proctor approval or without the proctor being present and watching the physician or dentist, the action constitutes a restriction of clinical privileges and must be reported to the NPDB. May 12, 2015 Credentialing & Privileging

Do NOT Report to NPDB Denials or Restrictions: Clinical privileges at appointment or reappointment that occurs soley because a practitioner does not meet a health care institution's established threshold criteria for that particular privilege (as these are not the result of a professional review action relating to professional competence or conduct.) If a hospital or other health care entity retroactively changes the threshold criteria for a particular clinical privilege, a physician who does not meet the new criteria will lose previously granted clinical privileges. May 12, 2015 Credentialing & Privileging

Generally, Do NOT Report to NPDB
Voluntary withdrawal of an initial application for medical staff appointment or clinical privileges prior to a final professional review action generally should not be reported to the NPDB. Non-renewals of medical staff appointment or clinical privileges. May 12, 2015 Credentialing & Privileging

NPDB Requirements Provides Additional Information & Examples: Defines “Investigation” 30-day requirements Timeline for reporting Specific adverse events to be reported Professional to be reported Generating Reports Initial Reports Corrected Reports May 12, 2015 Credentialing & Privileging

References CMS Final Rule: Burden Reduction May 12, 2014 CMS Survey & Certification Memo ( ) CMS Survey & Certification Memo ( ) CMS Acute Care Hospital Interpretative Guidelines – Appendix A ( ) National Practitioner Data Bank ( ) Link = May 12, 2015 Credentialing & Privileging

Post Test Copy the URL listed below and paste into your browser to access the test on Testmoz. To access: Test name: Credentialing and Privileging - What Executives Should Know Type your 1st and last name where indicated PASSWORD: credentialing (lower case) May 12, 2015 Credentialing & Privileging

QUESTIONS? Karen Beem 312-202-8069 Donna Tiberi 312-202-8073
Please submit questions to: May 12, 2015 Credentialing & Privileging

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Credentialing & Privileging What Executives Should Know May 12, 2015

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