Credentialing

Contents

Delegated Credentialing-Credentialing in CVO

Credentialing in Payor Organizations

Credentialing in Provider Organization

Accreditation

Overview of Credentialing

Generic Credentialing Process

My Credentialing Model

Certifications on credentialing

Potential Business Areas

OVERVIEW OF CREDENTIALING

Credentialing/ Privileging

Select Competent provider

Assessing qualification

Verifying

Obtaining Information

Credentialing

• This Process Determines, Admittance or Rejection of a provider into a Healthcare Organization

For existing Affiliated practitioners:

• It serves to reassess the individuals continued appropriateness for practicing in the institution“Recredentialing”

Privileging:

• It is defined as authority given to practitioner to provide specific care service in an organization within well-defined limits, based on evaluation of the credentials and performance

PSV and Ongoing Monitoring

Primary Source VerificationIt is a process through which an organization validates credentialing information by contacting the organization that originally issued the credentialing elements to the practitioners

E.g.: The state dept that issues license to a practitioner is the primary source for verification of the validity of that license.

Ongoing MonitoringProvider who are admitted into the organization are subjected to on goingmonitoring and valuation to ensure competence.

Renewal of Credentialing (Recredentialinng) Renewal of privileges

Snap Shot of Credentialing in US

More than 5,000,000 US practitioner

Credentialed by more than 150,000 Healthcare Organizations

In accordance with 50 individual state requirements

As well as JACHO NCQA, URAC, CMS, AAAHC, HFAP

As well as individual Organizational thresholds for review

Why Credentialing?

A case of Negligent Credentialing:

In Mid-1980 a local doctor performed a erroneous surgery on a child and he died. It was found during the trial that the provider was never granted a surgical privilege. At trial, the hospital was found to be 18% negligent and the doctor 82% negligent. The Verdict was 10 million dollars.

Why do we do credentialing…?

The primary purpose for

credentialing is to ensure and

promote quality service to patients

Choose competent & Qualified

providers

A Study found 73% of the most severe injuries caused by the providers were preventable.

One of the solution is Stricter Credentialing of LIP

Along with ongoing monitoring

Driving Force

Quality

AccreditationStandards &

requirements

Case Laws

Regulatory Requirements

Risk Management

Customer & Payor

Expectations

Evolution of credentialing

1900’s

American College of Surgeons created basic standards physicians and

surgeons

Foundation for credentialing process

was set

1970’s

Joint Commission Hospital Accreditation

program

They set accreditation credentialing

standards

1980’s

Primary source verification,

Reappointment process

Computers replaced electronic typewriters

Health Care Quality Improvement Act

verification service offered by Medical

societies

National Committee for quality Assurance

(NCQA)

1990’s

Beginning of online verification services

Required use of National practitioner Data Bank (NPDB)

MCO’s started to Delegate

credentialing activities to IPAs, Hospitals or

CVOs

2000

CAQH- Council for affordable Quality

Heath care

Outsourcing the work to foreign countries

begun

Who is credentialed?

Participation

Membership

Affiliation

CertificationPrivileges

Credentialing Happens During

Healthcare Organizations

IndividualProviders

Who is Credentialed?

E.g.: Doctor , Nurse, Dentist… etc

E.g.: Hospitals, Rehab…etc

Laws that Affect Credentialing process

State Laws

Antidiscrimination Any-Willing-

Provider Licensure Peer Review Disclosure of

selection criteria Economic Profiling

Federal Laws

American with Disabilities Act

Health Care Quality Improvement Act

Medicare Conditions of participation

Health Maintenance Organizations Act

Text

Case Laws

Laws That Affect

Credentialing

GENERIC CREDENTIALING PROCESS

Basic Credentialing Process Steps

APPLICATION• Identification of

practitioner/provider• Prescreening• Completion of application• Return application to processing

org

VERIFICATION AND INFO GATHERING

Credentials file is developed as data and info are

collected

ANALYSISReview and evaluation of

information in file

DECISIONAnd notification to applicant

Monitoring and

evaluation

All or part of verification may be

outsourced or delegated

Recredentialing every two years

Elements which are verified

Elements Website ImageMail/Fax/E-

mail Phone callElectronic

Query

DEA - - -CDS - - -PLI - - - -

State License - -Board - -

Education - - -Work History - - -

Hospital Affiliations - -Medicare/Medicaid Opt out - - - -

OIG - - - -GSA - - - NPDB - - - - HIPDB - - - - FSMB - - - -

OIG and GSA

GSAThe United States General Services Administration (GSA)

oversees contracts with the Federal government.

They maintain a list of parties excluded from doing business with the Federal government, including healthcare programs receiving Federal funding or reimbursement

Most GSA Excluded Parties are vendors or corporations, but some may be individuals with their own businesses.

OIGThe Department of Health and Human Services Office of

Inspector General maintains a list of sanctioned individuals. Most OIG Sanction reports pertain to individuals – such as a specific practitioner.

It includes any action taken on Fraud, Waste, Mismanagement, Abuse, and Corruption

NPDB and HIPDB

Healthcare Integrity and Protection Data Bank (HIPDB)

The purpose of HIPDB is to combat fraud and

abuse in health care insurance and health care

delivery.HIPDB contain adverse actions taken

againsthealthcare providers, suppliers and

practitioners

The following types of actions are included in

HIPDB: Civil judgments Criminal convictions Actions by Federal or State licensing

and certification agencies Exclusions from participation in

Federal or State health care programs Other adjudicated actions or decisions

as established in regulations.

National Practitioner Data Bank(NPDB)

The National Practitioner Data Bank (NPDB) was created by the Health Care Quality Improvement Act of 1986 to track information on physicians and dentists.

The following types of actions are included in NPDB:

Adverse licensure actions Clinical privileges actions Professional society actions Medical malpractice payments made

on behalf of all health care practitioners, including nurses.

ACCREDITATION

Accreditation

Accreditation is an evaluation process in which a healthcare organization undergoes an examination of its operating procedures

To determine whether they meet designated criteria To ensure that the organization meets specific level of quality.

Accreditation Adds value to the Organization It acts as an External seal of approval Promotes quality improvement

Accrediting Bodies

NCQA

URAC

JACHO

AOA

CARF

AMAP

Accrediting Bodies

JACHO

Joint Commission on Accreditation of Healthcare Organizations ( Joint Commission)

The American College of Physicians, The American Hospital Association, The American Medical Association and Canadian medical Association joined with the American College of surgeons to form Joint Commission

They have introduced ORYX. Scope of service:

Ambulatory care Behavioral healthcare Home Care Hospital Long-Term Care Health Care network Clinical Laboratory Preferred provider

Organization

URAC

URAC is a non-profit, charitable organization that has issued over 1,600 accreditation certificates to more than 300 managed care organizations

Doing business in all 50 states.

URAC has over 16 accreditation and certification programs

Scope of service: Hospitals HMOs PPOs TPAs Provider groups

NCQA

They have 8 accreditation programs and certification programs

They have also introduced the HEDIS and CAHPS

Scope of Service: Managed Care

Organizations Managed Behavioral

Health care Organizations

Credentialing Verification Organizations

Physician Organizations

New Health Plan

The URAC Credentialing Support Certification (CSC) standards are designed for international

and domestic organizations that gather data for provider networks and CVOs in order to verify

the credentials of health practitioners.

Organization that Credential

•Hospitals•IPA

•CVO

•HMO•PPO•POS

CVO

Payor Organizations

Provider Organizations

CREDENTIALING IN PROVIDER ORGANIZATIONS

HOSPITAL CREDENTIALING

• Hospitals• IPA

• CVO

• HMO• PPO• POS

CVO

Payor Organizations

Provider Organizations

Credentialing in Hospital

Credentialing in hospital is performed by Medical Staff Coordinator

Medical Staff Coordinator do credential verification during: Initial Appointment Re-appointment Privileges Re-privileges

Bylaws of medical staff organization includes description and responsibilities of

Qualification for medical staff membership Categories of medical staff Medical executive committee Medical staff departments Credentials committee

REQUEST FOR

APPLICANTION

IS APPLICATION COMPLETE ?

APPLICATION SENT TO APPLICANT

INFO RECEIVED FROM APPLICANT

APPLICATION STILL TREATED

INCOMPLETE.APPLICANT NOTIFIED

FURTHER INFO REQUESTED

APPLICATION RECEIVED

MSO VERIFIES THE INFO

Yes

NO

APPLICATION REVIEWED

DEPARTMENT CHAIR MAKES WRITTEN REPORT AND

RECOMMENDATION FOR DELINIATION

APPLICATION SENT TO AND RECIVED BY CREDENTIALS

COMMITTEE

CREDENTIALS COMMITTEE REOMMENDS:A. APPROVED WITH NO ESTRICTIONSB. APPROVED WITH QUALIFICATIONS OR CONDITIONSC. DENIAL

INFORMATION SENT TO AND REVIEWEDBY EXECUTIVE COMMITEE

EXECUTIVE COMITTE RECOMMENDSA. APPROVAL WITH NO RESTRICTIONSB. APPROVAL WITH QUALIFICATION OR CONDITIONSC. DENIAL OF ALL OR PART OF APPLICATION

IS THERE ANY DENIAL

RECOMMENDED?

APPLICANT NOTIFIED INCLUDING RIGHT TO

HEARING

HEARING RIGHTS

EXERCISED?

GOVERNING BODY MAKES

DECISION. APPLICANT NOTIFIED

Yes

SENT TO GOVERNING BODY FOR FINAL ACTION

NO

APPLICANT NOTIFIED

DUE PROCESS HEARING HELD

NO

EXECUTIVE COMMITTEE AND APPLICAT NOTIFIED

OF RESULTS

APPELLATE REVIEW

REQUEST?

APPELLATE REVIEW HELD BEFORE GOVERNING BODY

Yes

FINAL DECISION

MADE PARTIES NOTIFIED

NO FURTHER ACTION

REQUIRED

NO

NO

Yes

Credentialing in Hospital

Yes

CREDENTIALING IN PAYOR ORGANIZATIONS

MCO CREDENTIALING

• Hospitals• IPA

• CVO

• HMO• PPO• POS

CVO

Payor Organizations

Provider Organizations

Payor Organization-MCO

Managed Care Organization integrate the financing and delivery of healthcare within a system.

To Ensure health plan member access to

Necessary Services

Provide high quality care

Improve cost effectiveness

of care delivery

MCO =

New Math

Network Of Providers

Contract--------------------------------------------------------

+

Characteristics of Managed Care Organizations:

• A panel of affiliated or contracted practitioners and providers

• Limitation of benefits if a non-contracted provider is used

• An authorization system

Ways through which credentialing is handled

In-House Credentialing

• Quality Management

Function

• Provider Relations

Rep

• In-house credentialing

Dept

Credentialing In MCO

Delegated Credentialing• CVO

• Hospital

• IPA

• Other provider organizations

Organizational Structure of an MCO

Basic Steps for credentialing in MCO

1

Market

Analysis

2

Define scope

of service

3

Design the

panel size

5

Collect and

verify

provider’s

credentials

6Analysis and

decision

7

Recredential

-ing

4

Identification

of potential

Providers

8

Maintenanc

e and

problem

resolution

Credentialing Process in MCO

Delegation of credentialing Process to another

Organization for Specified Practitioners and /or

Providers

Preapplication Application

Verification

Information Gathering

Office Evaluation

Medical Record Review

Delegation of Verification to a

CVO

File development

Review and Approval or decline

to credential

Rrecedential

Structure of Credentialing Process

Data Collection and File Maintenance

Review and Recommendation

Approval ( May be delegated to credentials Committee/

Administration/ Medical director by governing Board)

Contract or Letter of Agreement After Initial

Credentials Approval

Activity Accountability

Credentialing Staff

Credentialing Committee or Review Body

Medical Director

Governing Board

Provider Relations / Contracting

Office evaluation & Medical Record Review

Office Evaluation

Office evaluation is handled by the recruiter or a well trained Nurse

They evaluate the provider's office on:

Capacity to accept new members Office Ambiance Quality management Compliance with Health

Administration guidelines Presence of certain type of

equipment (e.g. defibrillator) Cleanliness of the office Friendliness of the staff towards

patient General atmosphere

Medical Record Review

Medical director review a sample of medical record

Purpose of this review is to assure,

Physician practice high-quality medicine

His practice is already cost effective

Difference in credentialing activity between Hospital and MCO

Number of Practitioners credentialedScopeBylaws Versus ContractsAccrediting Organizations and standardsAppointmentPrivilegingPhysician Office Site visits and Medical

Record Review

DELEGATED CREDENTIALING -CREDENTIALING IN CVO

DELEGATED CREDENTIALINGCVO CREDENTIALING

• Hospitals• IPA

• CVO

• HMO• PPO• POS

CVO

Payor Organizations

Provider Organizations

Delegation

Delegation is a formal process through which a Healthcare organization transfers to another entity the authority to conduct certain functions on behalf of the health plan.

It is governed by various accrediting and regulatory bodies and by state laws

To reduce the risk of delegation the delegating entity establish a formal program for oversight of delegated function

Oversight of the delegated activities is done by:

The Credentialing CommitteeQuality Management CommitteeUtilization Management Committee

Activities that are delegated

Activities that are delegated by an MCO Credential Verification Medical Record Review Site review Peer Review

Activities that are delegated by a Hospital or a provider organization

Filling of provider’s Application Credentialing Verification Peer review

Potential Delegates

Potential Delegates of an MCOHospitals and Other facilitiesProvider OrganizationsCredential Verification Organization

Potential Delegates of a HospitalCredential Verification OrganizationPractice management organizations

CVO

CVO: Credential Verification OrganizationThey link providers to hospitals and managed care

organizationsThey do the credential verification on provider’s, behalf of

healthcare organization

Services Offered by a CVO: Primary source Verification Distribution of Application and reapplication to practitioners Oversight and follow up on proper completion of application File maintenance of time sensitive documentation track expiable like license renewals and recredentialing

deadlines, and support through routine NCQA/URAC compliance audits.

Monitoring of licensure and government Agency sanctions

CVO over In-House Credentialing

Managed care organizations and other Healthcare Organizations have long depended on CVOs to provide credentialing services because

Lowering their liability Offer better turnaround time Lower overhead and expense Reduced staff time of managed care groups Lower liability to managed care groups Lessen the risk of penalties for errors during NCQA/URAC audits. Help reduce staff time and training Any problems with a provider will be notified immediately to the

managed care organization’s review committee. They offer extra services, such as tracking expirables like license

renewals and recredentialing deadlines, and support through routine NCQA/URAC compliance audits.

CVO Organizational Chart

MCO sends request for credentialing / recredentialing

CVO Send’s app to provider

Is Application

received

Is Application Complete

Verify the provider’s credentials

Send a report on the provider to the MCO

• CVO’s do not have authority to accept or reject a provider from network

• They only Collect and very the credentials of the provider and

• Send a report to the MCO or other organization, on the provider’s credentials

Credentialing process in a CVO

NO

Yes

NO

Yes

ADDITIONAL INFO ON CREDENTIALING

DISASTER CREDENTIALINGCENTRALIZED APPROCH TO CREDENTIALINGINFORMATION TECHNOLOGY BOOSTS CREDENTIALING

Disaster Credentialing

Post 9/11 JACHO developed “Disaster credentialing”

Disaster privileges may be granted when the emergency management plan has been activated

When the organization is unable to handle the immediate patient needs

Verification of the credentials and privileges of individuals begins as soon as the immediate situation is under control

Centralized Approach to Credentialing

To avoid replication of credentialing process

Reduce Administrative costEfficient credentialing

Examples for centralized credentialing approach

CAQHABMSOneSourceFederal Credentialing

Program (FCP)

Information Technology Boosts Credentialing

Helps Streamline otherwise tedious credentialing

Verification of credentials made onlineOnline ApplicationsSoftware to generate same provider’s info into

organization specific applicationMaintaining of massive amount of information

storageSpeedy access of informationHelps reduce Turnaround timePaperless credentialing reduces

Administrative cost

CERTIFICATIONS

CERTIFICATION TO BECOME A PROFESSIONAL CREDENTIALER

Certification on Credentialing

(CPCS) Certified ProviderCredentialing Specialist

Participate in the development implementation of Credentialing process, procedures Governance by laws Department rules and regulations Medical staff Practitioner/provider policies

Maintaining an accurate practitioners database

Collecting and analyzing verification information

Certified Professional Medical Staff Management

(CPMSM) Responsible for maintaining

compliance with regulatory and accrediting bodies

Developing and implementing credentialing process, procedures

Overseeing development of and adherence to Governance by laws Department rules and regulations Medical staff Practitioner/provider policies

May also be responsible for overall management of medical service functions

CPCSCPMSM

POTENTIAL BUSINESS

POTENTIAL BUSINESS AREASTOP CVOsTOP 10 MCOs

Potential Business Areas

COGNIZANTCOGNIZANT

Potential Business

CVO MCOAmbulatory

Care OrgIPA /

Hospitals

Potential Customers (CVOs)

Medadvantage

Providing credentialing services to MCO’s and MBHO’s in all 50 states, the District of Columbia

Has databases of One Million medical practitioners and Six Million verifications

Their IT partner

Their BPO partner

Medversant

Web-based credentials verification includes over 800,000 providers in its Encompass™ platform

MedVentive

Founded as the internal CVO for the CareGroup Health

System

Potential Customers

Top 10 Publicly Traded MCO’s in US

Company Revenue

Total Enrollment

United Health Group $20.2 Billion 30.3 MillionWell Point Inc $15.3 Billion 35.3 MillionAetna Inc $7.8 Billion 17.7 MillionHumana Inc $7.1 Billion 8.4 MillionCIGNA Corporation $4.1 Billion 11.9 MillionHealth Net Inc $3.8 Billion 6.7 MillionCoventry Health Care Inc $3.0 Billion 3.7 MillionAmeri Group Corp $1.1 Billion 1.7 MillionCentene Corp $897.1

Million1.2 Million

Molina Health Care Inc $791.6 Million

1.2 Million

List of Health Insurance Co

MY CREDENTIALING MODEL

My Credentialing Model

CVO

CAQHHospitals

MCO

GSA

OIG

Providers

HIPDB

NPDB

Buy verified info

Get excluded list every Month

Query

Buy Verified info

Fill a

pp

Reatte

st a

pp

(120

day

s)

Provider app is downloaded

Send Hospital

Roster

Help CVO in verifying credentials.Authorize to release the info

Questions