COMPARATIVE DIFFERENCES OF MEDICAL STAFF and CREDENTIALING STANDARDS

COMPARATIVE DIFFERENCES OF MEDICAL STAFF and

CREDENTIALING STANDARDS

Debra R. Green, MPA, CPMSM, CPCSDirector, Medical Staff Services and General Pediatric Residency

Program

Stanford University Medical Center• Stanford Hospital & Clinics

• Lucile Packard Children’s Hospital

• Director of Medical Staff Services and Pediatric Residency Program for Stanford University Medical Center which includes Stanford Hospital and Clinics and Lucile Packard Children’s hospital in Palo Alto, CA.

• Oversight of a combined medical staff of approximately 2000 physicians, 300+ Advanced Practice Professionals and 78 General Pediatric Residents.

• CPMSM and CPCS in addition to a Masters of Public Administration(MPA) degree with a concentration in Health Care Management and Policy

• 20+ years of healthcare administrative experience; primarily academic.• Held previous leadership positions in New Jersey and Michigan. • Served as an Expert Witness in negligent credentialing and privileging

legal cases• NAMSS Director at Large on the NAMSS Board for 5 consecutive years.

Background

Overview of the main regulatory bodies◦ Who they are? ◦ What they do? ◦ Why they exist?

Overview of Credentialing/Privileging Standards ◦ Requirements◦ Compliance

Objectives

Who are they?◦ Government Organization◦ Surveyors are typically State DOH employees◦ Gives deeming authority to TJC, HFAP and DNV

What do they do?◦ Validate TJC◦ Can Survey For Cause

Why do they exist?◦ To ensure patient care and quality

Center for Medicare/Medicaid (CMS)

Who are they?◦ Private Organization

What do they do? - Unannounced Surveys - Tracer Methodology - Can Survey “For Cause” Why do they exist?

◦ To ensure patient care and quality

The Joint Commission (TJC)

Healthcare Facilities Accreditation Program (HFAP)

◦ Deemed Authority since 1965

◦ Surveyors are experienced healthcare professionals

◦ Recognized by Fed Gov, State DOH, Ins Carriers and Managed Care Organizations (MCO)

◦ Surveys are unannounced

Det Norske Veritas Healthcare, Inc (DNV)

◦ Deemed status since 9/08

◦ Certifies other companies in additional to healthcare

◦ Existed since 1864 (began in Norway) in US since 1898

◦ World wide reputation for quality and integrity

Other Authorities Deemed by CMS

Who are they?◦ Private Organization

What do they do?◦ Accredits: MCO’s, MBHO’s, PPO’s, NHP’s etc.◦ Certifies: CVO’s

Delegated Credentialing Agreements◦ Hospital does the work for MCO or Health Plan

National Committee for Quality Assurance (NCQA)

Who are they?◦ Private Organization, non-profit

What do they do? - Accredit Ambulatory Healthcare

Organizations, Surgery Centers, Community Health Centers and Medical/Dental Group Practices

- US Air Force and Coast Guard Why do they exist?

◦ To promote patient safety, quality and value for Ambulatory health care

The Accreditation Association for Ambulatory Health (AAAHC)

Who are they?◦ Private Organization, non-profit

What do they do? - Accredit Health Plans and Preferred Provider

Organizations (PPO)

Why do they exist?◦ To promote healthcare quality through

accreditation education and measurement programs

URAC

Verification of Medical EducationTJC NCQA HFAP URAC/AAAHC DNV/CMS

(I) Primary Source verification from Medical School

Alternate sources: AMA, AOA,

ECFMG

AAPA for PA’s

(I) Primary source verification of (Highest Level of Credentials)

Alternate sources: AMA, AOA, ECFMG (for foreign grads after 1986), state licensing agency (if the state performs PSV)

FCVS for closed residency programs

(I) Primary Source Verification of Medical Education

Must be significant to support request for privileges

Alternate sources: AMA, AOA, ECFMG (after 1986), state licensing agency

URAC – (I) PSV required

History of education and training included on app

Can use the state lic Board as a PSV

AAAHC – (I) PSV required

No alternative sources noted.

DNV (I) Primary Source Verification of Medical Education

Requirements must be outlined in Bylaws

CMS – Not specially addressed in standards (doesn’t mean its not required)

Post Graduate TrainingTJC NCQA HFAP URAC/AAAHC DNV

(I) PSV required from primary source or equivalent source

Alternate sources:AMA, AOA

(I) PSV Highest level of credentials (i.e. board certification)

Alternate sources: AMA, AOA, state licensing agency, transcripts (sealed), FCVS for closed programs

(I) PSV of Training required

Documentation must support requested Privileges

Alternate Sources:

AMA, AOA,

URAC – (I) PSV required only if not board certified

History of Education Required on app

Can use the state lic board as a PSV

AAAHC – (I) PSV required

No alternative sources noted.

DNV - Bylaws include criteria for determining privileges including, specific training requirements

CMS – Not specifically addressed in standards (doesn’t mean its not required)

PEER RECOMENDATIONSTJC NCQA HFAP URAC/AAAHC DNV and

CMS(I) Required(R) Required if there is insufficient practitioner-specific data availablePeer with knowledge of applicant

Recommendations should address clinical competence and ability to perform privileges

6 General Competencies

(I&R) Peer Review through Credentials Committee with representation from similar types and degrees of expertise

(I) Obtain at least1 peer with thesame professionalCredential

Assessment ofphysical and mentalhealth in relation toprivileges requested.

(R) Individual lettersnot required, can beobtained throughPR, Cred Com,Dept Chair or MEC

URAC – No specific requirement

AAAHC – (I &R)Peer recommendationrequired

DNV- 2 Peerrecommendations at(I). Nothing in thestandards assess PeerReferences at (R)

CMS – Not speciallyaddressed

How many organizations perform Work/Affiliation

History Verifications?

Work/Affiliation History Verifications

Work/Affiliation HistoryTJC NCQA HFAP URAC/AAAHC DNV/CMS

There is no specific requirement for verification of work history. The standards require, at the time of appointment to membership and initial granting of privileges, verification of relevant training or experience must be obtained from the primary source (s) whenever feasible.

(I) PSV not required.

A minimum of five years of relevant work history must be obtained through the practitioner’s application or curriculum vitae. Gaps exceeding six months must be reviewed and clarified either verbally or in writing.

(I) PSV Required

Verification of where the applicant previously had privileges with confirmation of the applicant’s appointment and privilege history, and any pending investigations of disciplinary actions, voluntary resignations, or relinquishments of membership/clinical privileges

URAC – Not addressed in standards

AAAHC – (I)Reviewed for

continuity and relevance.

Document interruptions in practice

DNV – Not addressed in standards.

CMS – Not addressed in standards

PrivilegesTJC NCQA HFAP URAC/AAAHC DNV/CMS

Clearly documented process for granting

Evidence of Physical Ability to perform requested privileges

Grant or Deny must be objective and evidence based

Must be criteria based

No requirement for privileges

Must be consistent with demonstrated competency

Criteria based

Surgical privileges must be delineated based on individual competency

URAC – Privileges must be included in the application

AAAHC – Criteria based

Reviewed and approved by the governing body

DNVCriteria Based

Practice within scope

CMSAll patients must be under the care of a practitioner with privileges

Privileges can only be granted by the hospitals governing body

Assess ability to perform

Temporary PrivilegesTJC NCQA HFAP URAC/AAAHC DNV/CMS

Can be granted under 2 conditions:

1. Urgent patient care need for limited time (PSV current license, NPDB and competency evaluation req)

2. New apps waiting for MS review and after a complete application and All verifications are complete

Note: No challenges to license, membership or privileges

Process for “provisional credentialing” for first time providers

PVS of license, NPDB, completed application with signed attestation

File must be valid and verified and approved by Medical Director or qualified physician

Must not exceed 60 days

Bylaws provide for the granting of temporary privileges:

1. During review and consideration of application. 2. For care of specific patient

3. For locum tenens. 4. For times of emergency or disaster.

PSV of Lic, DEA, Insurance and 1 Ref from previous facility req

URAC – Organization can grant “Provisional” Participation status for a limited time when justified by continuity or quality of care issues on approval of senior clinical staff person.

AAAHC – Not specifically addressed.

DNVUrgent Pt Care

Complete app w/o negative or adverse info

Not to exceed 30 days

Verification of Lic, competence, Ref and AMA (education), NPDB and OIG

CMSNot addressed

Ongoing Performance Monitoring

TJC NCQA HFAP URAC/AAAHC DNV/CMS

(I) FPPE – Focused evaluation (i.e. Proctoring)

(R) OPPE – Ongoing Evaluation (i.e. data assessment for everyone)

Added in MS Chapter in 2008

Not addressed Not addressed URACNot addressed

AAAHCNot addressed

DNVNot addressed

CMSNot Addressed

DEA/CDSTJC NCQA HFAP URAC/AAAHC DNV/CMS

(I & R) Doctor must provide information regarding previously successful or currently pending challenges or relinquishment of registrations

(I & R) Verify through copy of certificates, NTIS, AMA

State CDS certificates must be verified, where applicable

(I&R) Application includes actions against DEA/CDS

URAC – (I&R)Evidence of current DEA/CDS

May collect a copy of certificate or certificate #

Must be verified within 6 months of review and approval

AAAHC – (I) evaluated at initial appmt and monitored continually

DNV(I &R) Provider must provide current DEA #

CMSNot Addressed

CONTINUING MEDICAL EDUCATION(CME)


(I & R) LIPS must participate in Continuing Education

Documented

Considered in Privilege process

Should be relevant to clinical privileges requested

Not Addressed May request evidence of CME every 2 years

URACNot Addressed

AAAHCNot Addressed for Medical Staff Members

DNVShould participate in CME related to privileges

CME should be considered at reappointment

CMSNot addressed

MALPRACTICE INSURANCETJC NCQA HFAP URAC/AAAHC DNV/CMS

Not required unless outlined in bylaws

Most hospitals require it

Primary source verification not required

(I & R) Attestation by doctor or copy of policy showing dates and amount of coverage or Face Sheet from the carrier

Federal Tort letter or attestation from practitioner of Fed Tort is ok

Must have evidence of PLI coverage

Must have current certificates showing amount (s) of coverage

URAC – Proof of PLI included on application

A cover sheet or attestation from ins company is sufficient to prove coverage

AAAHC – Req only if organization requires it

Review information related to refused or cancelled coverage at (I&R)

DNVNot addressed

CMSNot addressed

MALPRACTICE HISTORYTJC NCQA HFAP URAC/AAAHC DNV/CMS

(I & R) evaluate evidence of “unusual pattern” or “excessive” number of actions resulting in a final judgment.

(I & R) Attestation by doctor or copy of policy showing dates and amount of coverage or Face Sheet

Verify history of claims that result in a settlement paid by or on behalf of the practitioner Confirm via NPDB or carrier last 5 years of settlements

(I&R) Doctor must provide malpractice history for past five years.

Organization verify history that resulted in settlements or judgments paid for practitioner.

Verified through carrier or NPDB

URAC – provider must include claims history on app

AAAHC - provider must include claims history on app and evaluated

DNV(I&R) organization must review involvement in any action

CMSNot addressed

NATIONAL PRACTITIONER DATA BANK(NPDB)


Must query at granting of initial, renewal and when a new privilege is requested.

Query if you can’t obtained last 5 years of claims from Insurance carriers.

Use as alternate source for sanctions or limitations on licensure

Must query at granting of initial and renewal

URAC - Not required, but can be used to verify license and Medicare and Medicaid sanctions

AAAHC - required at (I & R). PDS is acceptable.

DNV(I) required only if Temporary Privileges are requested

CMSNot addressed

BACKGROUND CHECKSTJC NCQA HFAP URAC/AAAHC DNV/CMS

Terminology is not used in Medical Staff Standards

Required under HR Hospital Standards

Not specially addressed

Application must attest to his/her history of loss of license and felony conviction and lack of illegal drug use.

*Attestation Statement

Application must request information regarding any criminal history.

Investigation must be conducted based on information provided on the application.

URAC –Not specially addressed

AAAHC - Not specially addressed

DNVRequired only if State requires it

CMSRequired only if State requires it

BOARD CERTIFICATION


Verification not required unless bylaws /policy require board certification

Organization Specific

Verify through ABMS, AMA, AOA or specialty board

Not required, but if practitioner says they are Board Certified, it must be verified

(R) Required to determine if still current

Verify Through ABMS, AMA, AOA, state licensing agency if confirmed by licensing board

(I) Not required, but if practitioner says they are Board Certified, it must be verified

URAC - Not required but verify if practitioner states they are board certified

AAAHC – Verify on initial application and ongoing basis

DNVNot addressed

CMSNot addressed

LENGTH OF APPOINTMENT PERIOD


May not exceed 2 years

At least every 36 months

Counts the 36 month cycle to the month, not to the day. (i.e Jan 5, 2007 to Jan 29, 2010 is ok)

May not exceed 2 years

URAC - At least every 36 months

Counts the 36 month cycle to Month AND day. (i.e Jan 5, 2007 to Jan 28, 2010 is NOT ok) it must be Jan 5 to Jan 5 every 3 yrs

AAAHC – as defined by state law, not to exceed 3 years

DNVMay not exceed 3 years (defined by state law)

CMSRecommends every 24 months

LICENSURETJC NCQA HFAP URAC/AAAHC DNV/CMS

(I & R) Primary source verification required at initial appointment, reappointment, revision of privileges and at time of expiration

Current and Valid

Verify through state licensing board

(I & R) Primary source verification

Must be current and valid

In effect at time of credentialing decision

Verify through state license board

(I & R) Primary source verification required

URAC – (I&R) PSV required Current and valid

AAAHC – (I&R) PSV required

DNV(I & R) Primary source verification required

CMSNot specifically

addressed in standards

LICENSURE SANCTIONSTJC NCQA HFAP URAC/AAAHC DNV/CMS

(I & R) The doctor must provide information regarding challenges or relinquishment of license

*Attestation question

State Licensing BoardFSMB can used as PSV

(I & R) Primary source verification required

Verify through state licensing board

NPDB/PDS and FSMB can be used as PSV

Application must include current or pending challenges

(I & R) Must be reviewed for each applicant

FSMB and FACIS can be used at PSV

URAC – History of sanctions should include at least a 5 yr history

NBDB can be used

AAAHC – review of sanctions required at (I&R)

DNVAddressed for TP only

CMSNot specifically

addressed

MEDICARE/MEDICAID SANCTIONS


Not addressed (I&R) Current or previous sanctions must be verified

Ongoing Monitoring required between re-credentialing cycles

Verify through AMA, NPDB, OIG, FSMB, FEHB, State Medicaid Agency

Application must request information regarding Medicare Medicaid Sanctions

URACMust be reported on application

Can use NPDB as PSV

AAAHCMust be disclosed and reported on application as well as evaluated at (I&R)

DNV(I) Must be reviewed before Temporary Privileges are granted.

CMSNot Specifically

addressed

Disaster PrivilegingTJC NCQA HFAP URAC/AAAHC DNV/CMS

Disaster privileges may be granted to volunteer LIPs when theEmergency Operations Plan has been activated

*removed from the MS Chapter, it now resides in EM 02.02.13

Not specificallyaddressed.

The hospital has a plan for dealing with clinical volunteers during emergency /disaster.

This plan should provide for primary source ID from the volunteer’shospital (A documented phone call is acceptable).

The hospital should use volunteers as appropriate within the scope of their license/certification.

URAC

Not specifically addressed.

AAAHC

When hospitalization isneeded due toemergencies, theorganization may have apolicy for credentialingand privileging physicians and dentists who have admitting privileges at a nearby hospital.

DNVNot specifically addressed.

Identification,availability andnotification ofpersonnel that areneeded to implementand carry out thehospital’s emergencyplans should beconsidered whendeveloping theComprehensive emergency plans.

CMSNot specificallyaddressed.

Be prepared to implement disaster privileges in the event of an

Emergency ……develop a process, not just a policy

Tool # 2 – Disaster Credentialing Tool Kit

Compliance Tips and Tools #1

Includes:

• Disaster Credentialing Policy• Employee Roster with Phone #s• Disaster Privileging Tracking Logs

(multiple copies) Disaster Privilege Forms

(multiple copies)• Excerpt from Bylaws regarding Disaster

Privileges• List of Links for licensure verification• Written process for staff to follow• Name Badges• Markers• Ink Pens

Disaster Credentialing Tool Kit

To be completed by Medical staff services

L Name F Name MD, DO, NP, PA, DDS,

DPM, PHD

Specialty Lic # Type IDProvided

(See Key – A required)

Lic Verified(Date)

VerifiedIn 72 hrs

Y/N

MS Member

Y/N

PRIVFORM COMP

Y/NSAMPLE DOCTOR MD MED 123456 A, B 1/1/09 Y N Y

DISASTER PRIVILEGES TRACKING LOG FOR VOLUNTEER LIP’S

ID Type KeyA – Govt issued ID – REQUIREDB – ID from another HC OrgC – License to practiceD – ID from DMAT/MRC/ESARVHPE – ID from Govt entity granting authority to provide careF – Confirmation from another Medical Staff Member

VOLUNTEER LICENSED INDEPENDENT PRACTITIONER DISASTER PRIVELEGES FORM

I, (print)_______________________________________, certify that I am licensed as a: Physician Podiatrist Dentist Psychologist Nurse Practitioner Physician Assistant in the State of_______________________, license #______________, and I certify that I have no restrictions on my licensure to practice. I also certify that I have the training, knowledge, and experience to practice in the specialty of ____________________________________ with no restrictions on clinical privileges at any hospital. I hereby volunteer my clinical services to Stanford Hospital and Clinics/Lucile Packard Children’s Hospital (“Hospitals”) during this emergency/disaster situation and agree to practice as directed and under the supervision of a current member of the Medical Staff at the Hospitals. I agree to wear my ID badge issued by the Hospitals at all times when functioning under these temporary disaster privileges to enable staff and patients to readily identify my status. I agree to abide by all policies at the Hospitals regarding confidentiality of patient information. I also acknowledge that my temporary disaster privileges at the Hospitals shall immediately terminate once the emergency has ended, as notified by the Hospitals, and that these privileges may be terminated at any time without cause or reason, and without right to a hearing or review. ____________________________________________________________ Signature of provider ____________________________________________________________ Date The information as provided by the provider has been reviewed and will be verified, as soon as possible, as outlined in the Policy, by Medical Staff Services. On this basis, this provider is herby granted temporary disaster privileges to treat patients presenting at the Hospital during this emergency/disaster. ____________________________________________________________ Signature of Chief of Staff (or designee) ____________________________________________________________ Date

Health Status AssessmentTJC NCQA HFAP URAC/AAAHC DNV/CMS

Applicant must submit a statement that no health problems exist that could affect clinical privileges

Confirmed by PD, Chief of Service or COS or at another hospital at (I) appmt or a Peer already on staff.

Medical staff must evaluate prior to recommending privileges.

Current signed attestation from the applicant attesting there are no health issues.

Documentation of Health Status included in Professional references

Can be a statement regarding the applicants physical or mental health status related to privileges requested.

URACApplication must include a question about physical mental or substance abuse problems

AAAHC

Organization requires and reviews issues regarding physical, mental and chemical dependency

DNV

Not specifically addressed

CMS


Allied Health ProfessionalsTJC NCQA HFAP URAC/AAAHC DNV/CMS

TJC does not use the term “allied health professionals.” It refersto LIPs and Non-LIPs.

PAs and APRNs must be credentialed, privileged, and re-privileged through the medical staff process or an equivalent process that has been approvedby the governing body.

Equivalent Defined as:Evaluate credentials, Current competence, Peer recommendations and input from committees including MEC to make a decision about privileges.

Non-physicianpractitioners who havean independentrelationship with theorganization andprovide care under theorganization’s medicalbenefits must becredentialed.

All practitioners providing medical care or conducting surgical procedures either directly or under supervision, whether employed by the hospital, a physician, or a contracted provider must be credentialed.

Annual competency/skill assessment required

URAC

All practitioners who areparticipating providers,provide covered health care services to consumers, and appear in the organization’s provider directory arecredentialed.

AAAHC

If allowed by theorganization, the boardmust provide a process for the (I) appointment,(R) appointment, andassignment or curtailmentof privileges and practicefor AHPs (based on Statelaw and evidence ofeducation, training, experience and competence

DNVNPs, PAs, DDS, PHD’s can be considered “medical staff in accordance with state law

No mention of requirement for credentialing and privileging.

CMSMS must be composed of MD and DO, but in accordance with state law, NP, PA CRNA, and CNM can be appointed to MS.

Physicians and non-physicians can be granted privileges

Applicant IdentityTJC NCQA HFAP URAC/AAAHC DNV and

CMSThere must be a mechanism to determine the applicant is theindividual identified in thecredentialing documents by viewing either a current picture hospital ID card or a valid picture ID issued by a State or Federal agency, such as a driver’s license or passport.



URACNot specifically addressed

AAAHCNot specifically addressed

DNV


CMSNot specifically addressed

Attestation StatementTJC NCQA HFAP URAC/AAAHC DNV/CMS


Statement from applicant required at (I) and (R) in order to inquire about:

Illegal Drug UseInability to performLoss of Lic/privilegesDisciplinary ActionsMalpractice CoverageFelony ConvictionsAttest that the application is correct and complete

Medicare deemed Organizations: Must be signed within 180 days of final approval

365 days for non-Medicare deemed Orgs

Although not specificallyaddressed in the standards, the Scoring Procedure for thestandard reflecting theresponsibilities for allcredentialed practitionersinstructs surveyors to review a select sampling of files to verify practitioners attest tothese responsibilities atappointment and reappointment.

URACThe application includes a signed and dated statement attesting that the information submitted with the application is complete and accurate to the practitioner’sknowledge.

Time limit is 180 days

AAAHC

The application includes a signed and dated statement attesting that the information submittedwith the application iscomplete and correct.

DNV


CMS


ComplaintsTJC NCQA HFAP URAC/AAAHC DNV/CMS

There must be a process for evaluation of the credibility of a complaint, allegation, or concern against a privileged provider.

A process to monitor and investigate member complaints related tothe quality of all practitioner office sites is required

Must conduct sitevisits for complaintsrelated to physicalaccessibility, physicalappearance andadequacy of waiting and examining-room space based on thresholds. Implements appropriate actions and evaluate the effectiveness of thoseactions at least everysix months, until deficient offices meet the thresholds.

QAPI functions includemonitoring of complaints.

URACPolicy must define parameters or triggersof potential quality of care issues that require further investigation.

AAAHC

Not addressed

DNV

The hospital mustdevelop and implementa formal grievanceprocedure, whichincludes a referralprocess for quality ofcare issues to theUtilization Review,Quality Management orPeer Review functions,as appropriate.

CMSThe hospital mustestablish a process forprompt resolution ofpatient grievances andmust inform each patient whom to contact to file a grievance.

Compliance with LawTJC NCQA HFAP URAC/AAAHC DNV/CMS

A governance standard holds the hospital’s governing bodyresponsible to comply with applicable law and regulation.

Leaders are responsible to be aware of and comply with local, State, and Federal regulations related to credentialing and privilegingof practitioners.

The administrativepolicies and proceduresindicate thatorganizations providingmanaged care servicesmust comply withapplicable Federal,State, and local lawsand regulations,including requirementsfor licensure. Thus, theorganization’s leadersare responsible for anyregulations relating tocredentialing.

Standards require compliance with applicable law andregulations.

URAC

Standards require compliance with all applicable Federal,State and local laws.

AAAHC

Standards requirecompliance with allapplicable Federal, State and local laws.

DNV

Standards requirecompliance with allapplicable Federal,State and local laws.

CMS

The governing body must assure that the medical staff has bylaws and thatthose bylaws comply with State and Federal law and the requirements of CoPs.

Use of a CVOTJC NCQA HFAP URAC/AAAHC DNV/CMS

Organizations that use information from a CVO should have confidence in the completeness, accuracy, and timeliness of that information.

Evaluation of agency can include; processes utilized, limitationsof information available, identification of primary source info versus secondary source information, quality control measure, data integrity, security and transmission.

CVOs are allowed to be used and credentialing policies and procedures include the process used to delegate credentialing and re-credentialing, what can be delegated, how the decision to delegate is made.

A mutually agreed upon document describing each organizations responsibilities is required

HFAP refers to a ProfessionalCredentialing Organization(PCO).

PCO can be used to perform the PSV, but the process forcredentialing by the organization must reflect the requirements as stated in the standards

URACThe organization candelegate credentialing to a network, group or clinic organization with which they contract.

Oversight is required

The organization must retain the authority to make credentialing determinations and must conduct an on-site survey every three years.

AAAHCCVO is allowedAssessment of CVO’s quality of work is required

DNV


CMS


Use of Designated Equivalent Sources


AMA – MD or PA Education

ABMS – Board Certification

ECFMG Foreign Medical Graduates

AOA – DO Education and Board Certification

FSMB – Licensure actions

NCCPA certification

NPDB – paid claims or privilege suspension/revocation

NCQA does not use thelanguage “designatedequivalent sources.” The standards refer back to the specific credentialing event to determine an NCQA approved source.

FSMB – Licensure actions



ECFMG Foreign Medical Graduates


ABMS – Board Certification

URACAMA – MD or PA Education



AAAHCRefers to “secondary source” list of 20

http://www.aaahc.org/eweb/dynamicpage.aspx?site=aaahc_site&webcode=resource_credential

DNV



CMS






Felony ConvictionsTJC NCQA HFAP URAC/AAAHC DNV/CMS

Not specifically addressed.

The application mustinclude a statementregarding felonyconvictions.

The application requestsinformation regarding any criminal history and a criminal background investigation is conducted based on information provided in the application or as required by Federal and State regulations.

URAC


AAAHC

The applicant mustprovide informationregarding criminalconvictions other thanminor traffic violations.

DNV

Not specificallyAddressed

CMS


Site VisitsTJC NCQA HFAP URAC/AAAHC DNV/CMS

Not required. The organizationimplements appropriateinterventions byconducting site visits of offices about which ithas received member complaints and those for which established thresholds areexceeded.

Not required. URAC

Not required.

AAAHC

Not required

DNV

Not required

CMS

Not Specifically addressed

Audit, Audit and More Audits!!!

Tool # 3 – Credentialing Audit Forms


EMPLOYEE #123

Front of File Folder SHC LPCH Privilege Tab SHC LPCH

Board letters # of cases filled in for Core & Spec privs (Reapps Only)

Temporary letters (New Apps only) Documentation for privileges (X-Ray with Initials, Sedation, etc...)

<90 days to Board Approval (New Apps only) Signatures of applicantService Chief Recommendation Form - All questions answered email (if forms received electronically)

** Electronic email approval attached?

** Date Service Chief approved file Insurance Verification

** Proctors assigned? Claims History

** Approvals dated prior to HCC Date? Insurance - CurrentProfiles includes Insurance & Medical Education (New Apps only)Profiles includes # of cases done for each privilege (Reapps only)

SHC NPDB PDS - Date verification printed (& Initialed)

MSO Checklist included/initialedLPCH NPDB PDS - Date verification printed (& Initialed)

MSO Checklist complete OIG - Date Verification printed (& Initialed)

Application Tab GSA - Date Verification printed (& Initialed)

Photo (New Apps Only) References TabProvider Verification ID'd (New Apps Only) Includes 2 ref for New AppointmentsIf more than 3 month gap in education or work history - documentation Includes 1 ref for ReappsYes answer on attestation form has documentation Hospital Verifications includedDate application signed by provider required less than 180 days to HCC approval AMA or Edu. Verification (New Apps only)

CV or Work History Included in month/year format & Initialed (New Apps only)

CME

OH&S Clearance HealthSteam confirmed (New Apps Only)

Academic Appt / Fast Fac Previous Reappointment Application SHC LPCH

Evidence Fee collectedReappointment Governing Board date less than 2 years since last reappointment

email (if forms received electronically) Previous Governing Board Letter includedLicenses Tab SHC LPCH Three Tier sheet includedMBC Expiration Date (& Initialed) QA folder SHC LPCH

** Date PSV Printed Health Practitioner Abuse Form

** Current at HCCs? USA Fact / PreCheck

** Current at Governing Boards? Signed Background Release ** Not currently expired? 2 Complete years of Performance Data

included (SHC Reapps Only)

** 805 clean = Should read "00"2 Complete years of QA Report (LPCH Reapps Only)

DEA Expiration Date (& Initialed) Activity reports since previous appointment

** Date PSV Printed Comments: ** Current through Gov Boards?

** All Schedules included (P)?

NPI Verified (& Initialed)

Board Certification Verified (& Initialed)

New App: __________ Reapp: __________

Physician Audit Checklist

HCC Dates: LPCH = 01/19/12 SHC = 01/23/12 Audited by _____________ Facility: SHC _____ LPCH ____180 Days = July 23, 2011 (LPCH) or July 27, 2011 (SHC)

Provider: _________________________________________ Service(s): _________________________________________

Faculty: _____ ACF: _____ Community: _____

QM/UM/Legal Tab

Sanctions & Issues Tab

APP Audit Checklist2012

Audit Date SHC 01/23/12 LPCH 2/14/12 Audited by _____________ Facility SHC _____ LPCH ____180 Days = July 27, 2011 (SHC) or August 18, 2011 (LPCH)

New App __________ Reapp _______ APP-Emp _____ APP-Non-Emp _____Board Letter included 5 Privilege Tab

Profile includes Insurance and Medical Education (for New Apps) Delegation of Svcs Agreement(SHC only)Checklist included/initialed Cert. of Competence (SHC Reapp only)Checklist complete Job Description (SHC only)Temporary Privilege Form (LPCH all; SHC some)Less than 90 days to Board approval ACLS / PALS (if required)Letter from Chief of Staff 6 QM/UM/Legal TabRecommendation form Insurance Verification

All questions answered Insurance CurrentAll boxes checked Claims HistoryAll signatures present 7 Sanctions & Issues TabDate Service Chief approved file NPDB - SHC - Date Verification Printed

Approval dated HCC or prior NPDB - LPCH - Date Verification Printed

Proctors assigned? OIG - Date D Verification PrintedElectronic email approval in file GSA - Date Verification PrintedApplication Tab 8 References TabYes answer on attestation form has documentation

New app = 2 peer (1 could be supervising MD)

Enter Date signed by provider required <180 days to HCC approval

Reapp = 1 peer

Provider Verification ID'd (Non Emp only) 9 QA folderPhoto included (New Apps Only) Health Practitioner Abuse Form

CV/Work history mm/yy format & initialed Inquiry ReleaseLicenses Tab USA Fact or PreCheckMBC Expiration Date 10 FinalDate MBC PSV Printed Reappointment date less than 2 years

since last reappointmentCurrent at HCC approval Previous Board Letter includedNot Currently expired Previous 4 tiered sheet includedFurnishing License expiration date (NP only - not mandatory)

Evidence Fee collected (Cred only)Date Furnishing PSV Printed Comments:DEA expiration date (required for Outpatient APP's Only)Date DEA PSV Printed

NPI VerifiedANCC, AANP or PNCB - Initialed

PA Certification expiration date (Initialed)Initials on all Primary Source Verifications (Licenses, NPI, OIG, GSA & NPDB)BLS / BCLS required

Provider ______________________________ Service ________________________

Not addressed under: NCQA URAC AAAHC

Very detailed standards for:TJCHFAPCMSDNV

Telemedicine

Prior to Last year, hospitals were required to credential and privilege all telemedicine providers at the “Distant location”. (Even Tele-radiologists in Australia).

CMS changed the rule and revised the standard in Last year; published May 2011

New standard effective July 2011

Hospitals can now rely on the credentialing and privileging of “Distant Site”

The Joint Commission and HFAP are derived from the CMS

Distant Site: The site where the practitioner providing the telemedicine services is located.

Originating Site: The location where the patient is being treated.

Telemedicine – TJC, HFAP, CMS

Source: The Searcy Exchange June 2011

Here are the options that hospitals and CAHs have under the new rule:

Option 1: Credentialing and Privileging Provided under ContractA distant-site telemedicine entity, acting as a contractor of services, furnishes its services in a manner that enables the originating-site hospital to comply with all applicable Medicare conditions of participation and standards (via contract).

OR

Option 2: Credentialing and Privileging Provided without a ContractThe distant-site hospital providing the telemedicine services is another Medicare-participating hospital.

ANDThe individual distant-site physician or practitioner is privileged at the distant-site hospital providing telemedicine services, and that this distant-site hospital provides a current list of the physician’s or practitioner’s privileges.

ANDThe individual distant-site physician or practitioner holds a license issued or recognized by the State in which the hospital whose patients are receiving the telemedicine services is located.

ANDThe originating-site hospital has evidence of an internal review of the distant-site physician’s or practitioner’s performance under these telemedicine privileges and provides the distant-site hospital this information for use in its periodic appraisal of the individual distant site physician or practitioner. (Sounds like OPPE to me!!)

OR

Option 3: Originating Site Credentials and Privileges practitioners at the distant siteOrganizations can credential telemedicine practitioners the same way that they would credential and privilege any other practitioner who provides patient care services to patients at the organization

Telemedicine – TJC, HFAP, CMS

If the hospital contracts for telemedicine to be used including the radiology, the hospital verifies that the radiologist is licensed and/or meets the other applicable standards that are required by State or local laws in both the state where the practitioner is located and the state where the patient is located OR is subjected to the credentialing and privileging process through the medical staff to be approved for providing this service for the hospital.

Criteria that includes aspects of individual character, competence, training, experience and judgment is established for the selection of individuals working for the organization, directly or under contract, and/or appointed through the formal medical staff appointment process; and, the personnel working in the organization are properly licensed or otherwise meet all applicable Federal, State and local laws.

The governing body is responsible for services furnished in the hospital whether or not they are furnished under contract. The organization must evaluate and select contracted services (including all joint ventures or shared services) (and non-contracted services) entities/individuals based on their ability to supply products and/or services in accordance with the organization’s requirements. Criteria for selection, evaluation, and reevaluation shall be established. The criteria for selection will include the requirement that the contracted entity or individual to provide the products/services in a safe and effective manner and comply with all applicable NIAHO standards, and standards required for all contracted services.

Telemedicine - DNV

ABOUT CMS…..

Regulation:◦ Organized medical staff ; operates under bylaws

that are approved by governing body; responsible for quality of care.

Compliance: ◦ Bylaws, R&R’s, Cred files, Quality Reports,

Meeting minutes

Medical Staff Organization

Regulation:◦ MS composed of MD’s, DO’s according to state

law; may also include others appointed by Governing Body.

Compliance:◦ MS Rosters, Cred Files, Minutes or approved

Bylaws categories.

MS Composition (a)

Regulation: ◦ MS must conduct periodic appraisals

Compliance:◦ Cred Files, Profiles, Summary Reports of

Credentialing activity, Board minutes documenting last 2 appraisals

MS Composition (a)(1)

Regulation:◦ MS must examine credentials of applicants for

membership and make recommendation to Board.

Compliance:◦ Definition of Creds Review Process in the Bylaws;

MS minutes that document review and recommendations.

MS Composition (a)(2)

Regulation:◦ MS must be well organized and accountable to

Governing Body for quality of Medical Care provided.

Compliance:◦ MS Org Chart, Bylaws Description, Board Minutes,

definition of MS Composition in Bylaws, Bylaws approval by Board

MS Organization & Accountability

Requirement:◦ MS must adopt & enforce. ◦ Must be approved by Board; include category

descriptions, H&P requirement and criteria for privileges to be granted; describe MS Organization and applicant qualifications;

Compliance:◦ Bylaws, R&R, Minutes, Medical Records (H&Ps),

Quality reports (H&P timelines data)

Medical Staff Bylaws

Requirement:◦ Secure in all cases of unusual deaths and for

med/legal educational interests. Compliance:

◦ R&R, Autopsy Policy, QA or PI reports; Medical Record Review.

Autopsies

As of 2007:◦ No more than 30 days before or 24 hrs after

admission Old Requirement:

◦ No more than 7 days before and 48 hrs after

History & Physicals (H&P)

Continuous Readiness:

Increase staff knowledge on policies, regulations, bylaws, rules and regulations, privileges

Tool # 1 – Credential Jeopardy Game


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Contact information:

Email: [email protected] Phone: 650-497-8920

Website(s) Stanford Hospital: http://medicalstaff.stanfordhospital.org/

Lucile Packard Children’s Hospital: https://intranet.lpch.org/mss/index.html;jsessionid=E579B5885A691DCEF80629F89C3D4E67.Int1

Questions????

mailto:[email protected]

http://medicalstaff.stanfordhospital.org/

https://intranet.lpch.org/mss/index.html;jsessionid=E579B5885A691DCEF80629F89C3D4E67.Int1

Documents

COMPARATIVE DIFFERENCES OF MEDICAL STAFF and CREDENTIALING STANDARDS