Verify and Comply: CMS, JC, NCQA, HFAP, and DNV Credentialing Standards Compared and Contrasted

Transcription

1 Verify and Comply:, JC,,, and DNV Credentialing Standards Compared and Contrasted Session Code: MN10 Date: Monday, October 23 Time: 12:45 p.m. - 2:15 p.m. Total CE Credits: 1.5 Presenter(s): Sally Pelletier, CPMSM, CPCS and Carol Cairns, CPMSM, CPCS

2 MSS 2017 Verify and Comply Carol Cairns, CPMSM, CPCS Sally Pelletier, CPMSM, CPCS Objectives Identify the credentialing standards for,,,, Explain the differences and similarities among and between the credentialing standards for each organization Describe the four steps of credentialing and the responsible parties for each step 1

3 MSS 2017 So many masters nd all the state licensing bodies Centers for Medicare & Medicaid Services Federal CoPs 1966 Deemed status Base for all accreditors Six year approval Initial validation surveys by states ccrediting Organizations 2

4 MSS 2017 Version of Standards CoPs & Interpretive Guidelines for Hospitals (SOM 11/20/15) 2017 Hospital Standards 2017 Hospital Standards Healthcare 2017 Hospital Standards (Version 16) July 2017 Standards (Health Plan) July 2016 Standards (CVO) ll things should be made as simple as possible, but not more so. lbert Einstein The 4 Step Credentialing pproach Step 1: Establish Policies & Rules Credentials Comm MEC Medical Staff Governing Board Step 2: Collect & Summarize Information Management Medical Staff Leaders Step 3: Evaluate & Recommend Department Chairs Credentials Committee MEC Step 4: Grant, Deny, or Modify Governing Board or Designated gent(s) 3

5 MSS 2017 Step 1: Establish Policies & Procedures uthorization for services Bylaws/ Credent P&P Practitioners covered Processing time limits Criteria based privileges MD, DO, + No LIP, PRN, P, + GB Bylaws MD, DO, + GB Bylaws + MD, DO + GB Bylaws Cred Cmte Plan directed Variable by element N/ Step 1: Establish Policies & Procedures uthorization for services Bylaws/ Credent P&P Practitioners covered Processing time limits Criteria based privileges MD, DO, + No LIP, PRN, P, + GB Bylaws MD, DO, + GB Bylaws + MD, DO + GB Bylaws Cred Cmte Plan directed Variable by element N/ Step 1: Establish Policies & Procedures uthorization for services Bylaws/ Credent P&P Practitioners covered Processing time limits Criteria Based Privileges MD, DO, + No LIP, PRN, P, + GB Bylaws MD, DO, + GB Bylaws + MD, DO + GB Bylaws Cred Cmte Plan directed Variable by element N/ 4

6 MSS 2017 When In Doubt, pply the 5 P s Our Policy is to follow our Policy. In the absence of a Policy, our Policy is to create a Policy. Step 1: Establish Policies & Procedures uthorization for services Bylaws/ Credent P&P Practitioners covered Processing time limits Criteria based privileges MD, DO, + No LIP, PRN, P, + GB Bylaws MD, DO, + GB Bylaws + MD, DO + GB Bylaws Cred Cmte Plan directed Variable by element N/ Policies and Procedures /: Governing body may determine other types of practitioners to include : Organized MS must privilege if providing a medical level of care : May include others as determined by governing body and medical staff and state scope of practice 5

7 MSS 2017 Policies and Procedures» Provider categories are plan directed» Practitioners who are licensed, certified, or registered by the state to practice independently» Practitioners who have an independent relationship with the organization Plan can direct its members to see a specific practitioner or group of practitioners (Note: This includes telemedicine providers who meet above criteria) Policies and Procedures» Not necessary to credential Locum tenens Practitioners who practice exclusively in the inpatient setting Practitioners who practice exclusively in free standing facilities and provide care only as a result of being directed to the facility (e.g., mammo center, surgery centers, urgent care, etc.) Step 1: Establish Policies & Procedures uthorization for services Bylaws/ Credent P&P Practitioners covered Processing time limits Criteria based privileges MD, DO, + No LIP, PRN, P, + GB Bylaws MD, DO, + GB Bylaws + MD, DO + GB Bylaws Cred Cmte Plan directed Variable by element N/ 6

8 MSS 2017 Processing Time Limits» Bylaws define process and time frames to include a recommendation be made to the MEC within 60 days of receipt of completed application Processing Time Limits» 180 days for HP/MBHO and 120 days for CVOs Licensure Board certification Malpractice history Sanctions Processing Time Limits» Prior to credentialing decision Education and training DE» ttestation statements to confirm application responses are correct and complete may be up to 365 days for HP/MBHO and 305 for CVOs Includes work history 7

9 MSS 2017 Processing Time Limits» Under Managed Care standards, application attestation and all required verifications must be within 6 months of organization decision Step 1: Establish Policies & Procedures uthorization for services Bylaws/ Credent P&P Practitioners covered MD, DO, + Processing time limits No Criteria based privileges LIP, PRN, P, + GB Bylaws MD, DO, + GB Bylaws + MD, DO + GB Bylaws Cred Cmte Plan directed Variable by element N/ Criteria Based Privileging» Interpretative Guidelines: If an individual is providing a medical level of care or performing surgical tasks, they must be privileged (a)(4) Surgical privileges must be delineated for all practitioners performing surgery in accordance with the competencies of each practitioner 8

10 MSS 2017 Criteria Based Privileging relies upon the definition of surgery developed by the merican College of Surgeons Surgery is performed for the purpose of structurally altering the human body by the incision or destruction of tissues. Surgery is the diagnostic or therapeutic treatment of conditions or disease processes by any instruments causing localized alteration or transposition of live human tissue which include lasers, ultrasound, ionizing radiation, scalpels, probes, and needles. The tissue can be cut, burned, vaporized, frozen, sutured, probed, or manipulated Criteria Based Privileging» Interpretive guidelines for SS.3 Practitioner Privileges: Core privileges for general surgery and surgical subspecialties are acceptable as long as the core is properly defined Step 2: Gather Information License Education & training Experience Current competence Health status P+ + REF P P 9

11 MSS 2017 Step 2: Gather Information License Education & training Experience Current competence Health status P+ + REF P P License requires of licensure at:» Initial privileging (+ additional privilege request)» Re privileging» t expiration does not require of challenges to licensure» sk applicant re: voluntary or involuntary relinquishment License» Requires documentation: License history ll current licenses and ll applicable license sanctions» Licensing sources: and NPDB query» Sanction sources: (above +) FSMB or FCIS 10

12 MSS 2017 License» Requires : Initial appointment Reappointment Temporary privileges» Requires mechanism in bylaws: Suspension Revocation Restriction of license License» Requires documentation of: Expiration date Verification of license for all states where the practitioner provides care for the plan s members 180/120 days» Requires verification of sanction status for past 5 years, all states where they worked 180/120 days Sources for sanctions for MD/DOs: State licensing body, NPDB, or FSMB Step 2: Gather Information License Education & training Experience Current competence Health status P+ + REF P P 11

13 MSS 2017 Education and Training,,, accept ECFMG, M, and O verification accepts ECFMG and M verification accepts FCVS for closed residency programs Static information verified once Education and Training The Joint Commission (FQ)» llows for of licensing to suffice if the following are not important: Location of school The marketing of educational status Currency of education and training to clinical privileges Education and Training» llow for use of M and O Master Profile for of education for temporary privileges» Only list the M Master Profile as acceptable for appointment and reappointment 12

14 MSS 2017 Education and Training» Verification of highest certification or training is adequate Compliance vs. leading practice» Credentialing P&Ps ensure practitioner directories/marketing materials are consistent with credentialing data obtained, including education, training, certification, and specialty Education and Training (nnual written confirmation required)» State licensing agency, specialty board, or registry education if performed» State licensing agency residency if performed Sealed transcripts Step 2: Gather Information License Education & training Experience Current competence Health status P+ + REF P P 13

15 MSS 2017 Experience» Requires applicant provides information of work history ppointment Privileges Employment» Requires verification of above, plus Pending investigations Disciplinary actions Voluntary resignations or relinquishment Experience» No requirement for verification. Requires applicant document the most recent 5 year relevant work history. If less than 5 years, applicant must include beginning & ending month/year for each position» Documented review of work history by reviewer (signature/initials and date) on application, CV, or checklist» Gaps of >6 months need verbal explanation by applicant with documentation» Gaps of >12 months need written explanation by applicant Step 2: Gather Information License Education & training Experience Current competence Health status P+ + REF P P 14

16 MSS 2017 Current Competence,, : Requires evidence of individual character, competence, training, experience, judgment : Requires verification of professional and clinical performance (Suggested: six areas of General Competency) : Requires collection of clinical activity: procedure logs with outcomes to support privilege requests Current Competence Peer References : Supporting references for competence : of professional and clinical performance» Initial appointment must include peer references» Reappointment only if insufficient clinical activity Current Competence Peer References :» Initial appointment must include two peer recommendations» Reappointment only if insufficient clinical activity :» Initial appointment must include professional references regarding current competence and ability to perform» Reappointment only if insufficient clinical activity 15

17 MSS 2017 Current Competence Reappraisal of Privileges» ppraisal at regular intervals to evaluate individual s qualifications and demonstrated competency &» Ongoing professional practice evaluation results Current Competence Reappraisal of Privileges : Requires of clinical competence to include review of performance data (if available) for variation from benchmark data» Variations Evaluated through the peer review process Documented through an action plan which includes improvement strategies Step 2: Gather Information License Education & training Experience Current competence Health status P+ + REF P P 16

18 MSS 2017 Health Status» One comment in the surgical privileges section under survey procedures requires a written assessment of the practitioner s health status (a)(4) Health Status» Requires applicant to submit a statement that no health problems exist that could affect ability to perform the privileges requested» MS evaluates documentation of evidence of physical ability to perform requested privilege Health Status» Requires evaluation of health status through at least one professional reference that comments on the applicant s physical and mental abilities to perform the privileges requested 17

19 MSS 2017 Health Status» Medical staff section is silent on evaluation of health status. However, the surgical privileges section under survey procedures requires verification of the practitioner s health status» Reasons for inability to perform the essential functions of the position Step 2: Gather Information NPDB Liability Malpractice insurance history coverage Medicare/ Board Medicaid certified sanctions DE Felony Bylaws P P & NPDB P+ P P+ Bylaws Bylaws P or NPDB P P Step 2: Gather Information NPDB Liability Malpractice insurance history coverage Medicare/ Board Medicaid certified sanctions DE Felony Bylaws P P & NPDB P+ P P+ Bylaws Bylaws P or NPDB P P 18

20 MSS 2017 NPDB» Interpretive guidelines require reporting to appropriate State and Federal authorities (to include NPDB) when privileges are limited, revoked, or in any way constrained NPDB Federal law requires query of the NPDB when granting:» Initial medical staff appointment (courtesy or otherwise) or clinical privileges (including temporary)» Requests for additional privileges» Every two years thereafter Continuous Query (CQ) is accepted by and all accreditors NPDB &» for initial privileging, renewal of privileges, and for new privilege(s) request(s)» for initial appointment, reappointment, and for temporary privilege(s) request(s) 19

21 MSS 2017 Step 2: Gather Information NPDB Liability Malpractice insurance history coverage Medicare/ Board Medicaid certified sanctions DE Felony Bylaws P P & NPDB P+ P P+ Bylaws Bylaws P or NPDB P P Liability Insurance Coverage» pplicant supplies evidence of professional liability insurance coverage including a copy of current insurance certificate showing amount and dates of coverage Liability Insurance Coverage» Standards do not include a requirement for verification of professional liability coverage» Standards do include a requirement that the MS bylaws provide for a mechanism for automatic suspension if a practitioner fails to maintain required coverage 20

22 MSS 2017 Liability Insurance Coverage» pplicant attests to the amount and dates of coverage even if the amount is zero or provides a copy of insurance face sheet» Coverage must be current at time of credentialing committee decision NPDB Step 2: Gather Information Liability Malpractice insurance history coverage Medicare/ Board Medicaid certified sanctions DE Felony Bylaws P P & NPDB P+ P P+ Bylaws Bylaws P or NPDB P P Malpractice History» MS evaluates evidence of unusual pattern or excessive number of professional liability actions resulting in a final judgment» Requires query of the NPDB information re: malpractice judgments/settlements is included 21

23 MSS 2017 Malpractice History Requires organizations to:» Query the malpractice carrier for a 5 year litigation history» Query the NPDB Malpractice History» Bylaws outline qualifications to be met by applicant that includes review of the individual s involvement in a professional liability action» Requires query of the NPDB information re: malpractice judgments/settlements is included Malpractice History» pplicant provides at least a 5 year history of malpractice settlements» Information is then verified from carrier or NPDB query 180/120 days 22

24 MSS 2017 Step 2: Gather Information NPDB Liability Malpractice insurance history coverage Medicare/ Board Medicaid certified sanctions DE Felony Bylaws P P & NPDB P+ P P+ Bylaws Bylaws P or NPDB P P Board Certification,,» hospital is not prohibited from requiring board certification when considering a MD/DO for medical staff membership, as long as certification is not the only factor Board Certification», if applicable, from specialty board, BMS, O, or M (designated agent)» Documentation of board certification status» cceptable sources are BMS or O 23

25 MSS 2017 Board Certification» Board certification verified from BMS or member boards or official Display gent O Official Profile Report M Master File State licensing body with annual confirmation Non BMS / Non O Board documentation that the board performs annual of education and training in accordance with P&P Board Certification» If specialty board does not provide an expiration date, the organization must verify that the board certification is current Step 2: Gather Information NPDB Liability Malpractice insurance history coverage Medicare/ Board Medicaid certified sanctions DE Felony Bylaws P P & NPDB P+ P P+ Bylaws Bylaws P or NPDB P P 24

26 MSS 2017 Medicare and Medicaid Sanctions» CoP: No requirement to verify sanction status» Medicare regulations: No payment if practitioner is sanctioned Medicare and Medicaid Sanctions» Not specifically required» Covered under expectation to adhere to all regulations (local, state, federal)» Required NPDB query will contain information re: sanctions Medicare and Medicaid Sanctions» pplication requests information regarding disciplinary actions taken or pending re: Medicare/Medicaid» Standards also require NPDB query (contains information re: sanctions) FSMB or FCIS query 25

27 MSS 2017 Medicare and Medicaid Sanctions» Query of the OIG Medicare/Medicaid Exclusions List is required when granting initial appointment, reappointment, temporary privileges» MS bylaws contain language for suspension in event of termination of Medicare/ Medicaid status Medicare and Medicaid Sanctions Verification from:» NPDB (CQ)» FSMB» Medicare Exclusion Database» State intermediary» OIG List of Excluded Individuals and Entities Federal Employees Health Benefits Plan Step 2: Gather Information NPDB Liability Malpractice insurance history coverage Medicare/ Board Medicaid certified sanctions DE Felony Bylaws P P & NPDB P+ P P+ Bylaws Bylaws P or NPDB P P 26

28 MSS 2017 DE DE reports to NPDB : Requires MS to evaluate challenges to registration : pplication requests information regarding actions against DE and CDS : current DE is included in qualifications to be met by the applicant and reapplicant DE : Practitioners who prescribe medications» Copy or documented visual of current certificate, or (state or national), NTIS, M, O» Pending a DE or CDS, the organization must have a process (documented) to require an explanation and to provide arrangements for that practitioner s patients who need a prescription requiring a DE Step 2: Gather Information NPDB Liability Malpractice insurance history coverage Medicare/ Board Medicaid certified sanctions DE Felony Bylaws P P & NPDB P+ P P+ Bylaws Bylaws P or NPDB P P 27

29 MSS 2017 Felony» HR standards require criminal background check be addressed by policy for employees (e.g., Physicians/ PRNs/Ps)» pplication requests information on criminal history (7 to 10 years)» Reapplication may request information since last reappointment cycle» Information is verified according to state or federal regulation and/or based on information Expectation is that background check is performed Miscellaneous Gather Information: Verification of Identity,,, : Not addressed : Viewed and documented at initial appointment only» Current government issued photo ID OR» Current hospital picture ID Note: Special circumstances for telemedicine Miscellaneous Correctness and completeness of the application» Faxed, digital, electronic, scanned, or photocopied signatures are acceptable» Signature stamps are not acceptable unless the practitioner is physically impaired and the disability is documented in the practitioner s file 28

30 MSS 2017 Miscellaneous Use of CVO, : CVO s are not addressed in the standards but are acceptable in practice : Requires adherence to 10 principles for CVOs : Standards address the use of a CVO for in accordance with the requirements for each element : Requires a delegated agreement with oversight. Oversight requirement is removed if CVO is certified by Miscellaneous Use of CVO Therefore,,,, and would accept the use of the M and the O Profiles for» License(s)» Education» Training» Board certification» DE» Sanctions Miscellaneous Use of CVO would accept the M and the O Profiles for» Education» Training» Board certification» DE 29

31 MSS 2017 Review, evaluate, summarize...» pplication/reapplication Verified information is reviewed, evaluated, and summarized by a credentialing professional The summary is a clear report of the review Credentialing errors Information error: Information existed that could have been known, but wasn t, and the information would have impacted a credentialing decision Decision error: The necessary information was known, but leaders failed to make the wise decision Steps 3 & 4: Recommend & pprove Department chair Credentials committee MEC Governing board R If depts. R Bylaws R-If depts. R R R 30

32 MSS 2017 Steps 3 & 4: Recommend & pprove Department chair Credentials committee MEC Governing board R If depts. R Bylaws R-If depts. R R R Steps 3 & 4: Recommend & pprove Department chair Credentials committee MEC Governing board R If depts. R Bylaws R-If depts. R R R Credentials Committee» Requires a credentials committee and/or function that makes recommendations to MEC on applications and requests for clinical privileges 31

33 MSS 2017 Credentialing Committee : P&Ps outline the process for» Participation and responsibility of Medical Director in credentialing program» Managing credentialing files that meet established criteria» Process for determining and approving clean files» Effective date Credentialing Committee» Real time virtual meetings allowed» meetings not allowed» Committee s discussion must be documented in its meeting minutes Evidence of thoughtful consideration Steps 3 & 4: Recommend & pprove Department chair Credentials committee MEC Governing board R If depts. R Bylaws R-If depts. R R R 32

34 MSS 2017 Steps 3 & 4: Recommend & pprove Department chair Credentials committee MEC Governing board R If depts. R Bylaws R-If depts. R R R Questions? 33