3/2/2014 HOSPITAL CREDENTIALING THE WHO, WHAT, AND WHY. Who needs to undergo credentialing? Who performs credentialing

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1 Christopher Davis PA-C, RT Associated Radiologists Ltd HOSPITAL CREDENTIALING THE WHO, WHAT, AND WHY Who needs to undergo credentialing? Medical Staff members, including Physicians, Physician Assistants, Nurse Practitioners, Certified First Assists, etc. New providers to insurance companies. Who performs credentialing Hospitals Malpractice insurance companies Commercial insurance companies Medicare/Medicaid The credentialing department will likely follow the National Commission on Quality Assurance (NCQA) requirements 1

2 What is needed? Current, valid license to practice Status of clinical privileges at the hospital designated by the physician as the primary admitting facility Education and training of the physician Applicant's board certification, if the physician says on the application that he or she is board certified What else is needed? Applicant's work history Valid DEA or Controlled Dangerous Substance certificate, as applicable Malpractice coverage that is current and adequate Applicant's history of professional liability claims that resulted in settlements or judgments paid by or on behalf of the physician More???? All of the information will undergo PRIMARY SOURCE VERIFICATION (PSV) PSV is the process of verifying credentials directlywith the source. For example, a credentialing office cannot accept a copy of a medical school degree as evidence that the physician graduated from medical school. The school must be contacted directly to verify the physician s attendance and graduation. PSV is required so that hospitals and credentialing offices do not receive fraudulent documents from applicants or other nonprimary sources. PSV is a requirement by accrediting bodies 2

3 So, that means? You must provide copies of all of your documents, which will then be verified by the CVO. Your diploma Your residency certificate (if applicable) Your state license Your DEA license Your state issued identification A picture of yourself Why is credentialing done? To protect the public To protect the credentialing organization To ensure quality care Why do they want to know all this stuff? Avoid fraud Avoid poor outcomes Cases 1. Dr. Swango 2. Matthew Scheidt 3. Frank AbagnaleJr. 3

4 Dr. Michael Swango Over the course of 14 years, from 1983 to 1997, Dr. Michael Swango, a medical school graduate utilized forged documents and other fraudulent means to secure various residencies and staff appointments, both in the United States and abroad. Over the course of his crime spree, healthy patients would mysteriously die, or coworkers would fall ill. His activities were brought to the attention of various hospital administrations and residency programs, who would discipline him or terminate his privileges, however he would secure employment in other states or facilities. The FBI estimates that he may be responsible for over 60 deaths, although he was tried and found guilty of only 3. He is serving 3 life sentences without parole. He method of murder was infusing poison or overdoses of medications into IV lines. Matthew Scheidt In 2011, Matthew Scheidt, 17, mistakenly obtained a badge identifying him as a Physician Assistant instead of the billing clerk position he was hired for. Found guilty of working in a Florida emergency room for weeks, he changed bandages, handled IV drips and helped to conduct physical examinations while impersonating a PA. At one point he even performed CPR on a patient who had suffered a drug overdose. <iframesrc=' width='640' height='360' style='border:none;'></iframe><br/><a href=" Entertainment News</a> <a href=" Business News</a> Frank Abagnale Jr For eleven months, he impersonated a chief resident pediatrician in a Georgia hospital under an alias. When filling out a rental application he impulsively listed his occupation as "doctor,". After befriending a real doctor who lived in the same apartment complex, he agreed to act as a supervisor of resident interns as a favor until the local hospital could find someone else to take the job. The position was not difficult for him because supervisors did no real medical work. However, he was nearly exposed when an infant almost died from oxygen deprivationbecause he had no idea what a nurse meant when she said there was a "blue baby." He was able to fake his way through most of his duties by letting the interns handle the cases coming in during his late-night shift, setting broken bones and other mundane tasks. 4

5 How long does it take? The industry standard is approximately 90 days from the time the application is completed to final Board approval. Most health care organizations advise submitting an application 90 days before a practitioner s start date. Why does it take so long? Credentialing Verification Offices (CVO s) that perform primary source verification have very little control over process time. The process is affected by verification sources (other hospitals, training programs, peer references, employers, etc.) responding to requests for information. Practitioners can greatly influence the length of time by contacting their sources and asking each source to mail or fax verification requests back as soon as possible. GOOD LUCK!!!! 5