Reasons for Audits. Performing Credentials File Audits. Credentials File Audits:Tools and Techniques for Compliance

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1 Performing Credentials File Audits Kathy Matzka, CPMSM, CPCS Reasons for Audits Comply with Requirements Negligent Credentialing Issues Tool for Performance Evaluation Everyone Makes Mistakes! 2 Medicare Conditions of Participation CoPs require criteria for determining privileges and for applying the criteria: Individual character Individual competence Individual training Individual experience Individual judgment 3 Kathy Matzka, CPMSM, CPCS 1

2 CMS Survey Procedures Review credential files to determine if the facility complies with CMS requirements and State law, as well as, follows its own written policies for medical staff privileges and credentialing Review the hospital s method for reviewing the surgical privileges of practitioners. This method should require a written assessment of the practitioner s training, experience, health status, and performance 4 How Audits are Performed 1. Determine process to be audited 2. Select files 3. Reviews file and log results 4. Compiled master report 5. Share results 5 Determine process to be audited New applicant Reapplicant Expirable 6 Kathy Matzka, CPMSM, CPCS 2

3 Element of Rev iew Score Comments Practitioner Name Application present, complete, signed 1 Peer References Received and appropriate 1 All Hospitals/Clinics Verifications received 1 NPDB Query 1 OIG Exclusion Query 1 Medicare Attestation Signature Page 1 PSV Medical School 1 Medical School diploma present 1 ECFMG verification (if applicable) ECFMG certificate present Fellowship Verification(s) Fellowship certificate(s) present PSV of Residency present 1 Residency certificate(s) present 1 PSV of [your] state license 1 Copy of [your] state license present 1 PSV of other state License(s) PSV of state controlled substance license 1 Health Assessment/immunization record present 1 PSV Board Certification 1 Current professional liability Insurance face sheet present with acceptable limits/tail/nose 1 PSV of professional liability Insurance face sheet present with acceptable limits/tail/nose 1 Current DEA Certificate present 1 AMA Profile Present 1 FSMB Query Present 1 Privilege Form Privilege form present and appropriate to specialty 1 Form signed by applicant 1 Form completed correctly 1 Form signed by department chair and completed 1 appropriately Justin Smothers, MD Credentials File Audits:Tools and Techniques for Compliance Determine process to be audited Identify elements for audit Accreditation Standards State regulations Bylaws/Policies/Procedures Include time frames (if required) 7 Creating the Audit Tool New Ap 8 Creating the Audit Tool - Reap 9 Kathy Matzka, CPMSM, CPCS 3

4 Creating the Audit Tool - Expire 10 Record Selection Options Random sampling Systematic sampling ( Nth selection ) Stratified sampling 11 Tracking Audited Files Keep record of all audits Try to audit all files over a period of time Continuous monitoring 12 Kathy Matzka, CPMSM, CPCS 4

5 Other Audit Tools NCQA Managed Care: Washington Credentialing Audit Tool (WCAT) AAAHC Credentialing Records Worksheet in Standards Manual 13 Reporting Results Department Meetings Support MSP/MSO Performance Review Medical Staff Meetings 14 Follow up Deficiencies Discuss the results with staff Evaluate and identify potential causes of deficiencies Develop plan for addressing causes 15 Kathy Matzka, CPMSM, CPCS 5

6 How Much Time? 500 files X 20 minutes 10,000 minutes / by 60 minutes about 167 hours (a little over 4 weeks) 50 work weeks in a year (with 2 weeks for vacation) You will have to spend 3.33 hours a week doing file audits. 16 Credentials Files What goes in? Format (sections, tabs, etc.) File retention policy How long to keep What to keep Access Electronic 17 Questions 18 Kathy Matzka, CPMSM, CPCS 6