Medical Staff Briefing

Transcription

1 A training resource for medical staff leaders and professionals Medical Staff Briefing P5 P7 P8 P11 Medical staff applications Ensure your medical staff applications collect the information that you want. Application instructions This sample instruction sheet for initial applicants can help make the credentialing process run smoother. Site-neutral Medicare payments How will credentialing and privileging be affected by the Bipartisan Budget Act of 2015? Patricia A. Furci, RN, MA, Esq., and Samuel J. Furci, MPA, explain. Credentialing in a network Clear expectations and support from leadership will help MSPs new to network credentialing. Volume 26 Issue No. 10 OCTOBER 2016 Improve quality and encourage physicians through incentives In recent years, more and more attention has been directed toward quality improvement and patient safety. Just as Syed Ahmed Hussain, MD, associate chief medical officer at the Detroit Medical Center (DMC), was part of a team that pioneered an incentive program to increase quality on core measures at the organization, such efforts are gaining ground across the country. Hussain attributes this rise to the Institute of Medicine (IOM) 1999 report, To Err Is Human, as the kickoff for this movement. The groundbreaking report estimated that 44,000 to 98,000 patients die every year from preventable medical errors. The IOM based its estimate on studies conducted in Colorado, Utah, and New York that examined data from as far back as 1984 on how often adverse events occur and how often those events lead to death. The percentage of those occurrences were then extrapolated to the 33.6 million admissions to U.S. hospitals in We ve made strides and progress, says Hussain. We ve had developments in terms of enhancing patient safety, but there is more work that is being done. A recent study conducted by researchers at the Johns Hopkins University School of Medicine and published in The BMJ estimates that more than 250,000 people die every year from medical errors, making them the third leading cause of death in the U.S. behind heart disease (611,000 deaths per year) and cancer (585,000 per year). That s shocking. There s still so much more work to do, Hussain says of the estimate. The researchers came up with this new estimate by analyzing scientific literature and four studies on medical error and death rates from 2000 to The studies included a 2010 report by the U.S. Department of Health and Human Services Office of Inspector General that estimated medical errors contributed to the deaths of 180,000 Medicare patients. The researchers then extrapolated their estimate based on hospital

2 Medical Staff Briefing October 2016 admission rates from Although everyone involved in healthcare would like to improve patient safety, implementing any changes to the way things are done can be a struggle, especially for physicians who have been in practice for years and used to a set way. The team at DMC came up with a way to target its youngest physicians, and show them from the start ways to improve patient safety and quality improvement. In 2014, Hussain (who was chief resident at the time) helped create a program at DMC, under the mentorship of DMC Chief Medical and Academic Officer Suzanne White, MD, MBA, that awards residents and fellows financial incentive payments for contributing to improvements in two of the quality measures that the facility noted room for improvement with performance on venous thromboembolism (VTE) prophylaxis and stroke care. Prior to launching the quality improvement initiative, compliance with some of the VTE prophylaxis core measure elements was about 80%, says Hussain. Prevention of VTE is an extremely important quality issue and one of the leading causes of hospital-acquired conditions, so we had plenty of work to do. Hussain and his collaborators came up with the improvement program when DMC was in the process of being acquired by Tenet Healthcare. Among the changes the transition carried were reporting expectations for additional core measures, including VTE prophylaxis and stroke care. Another driving force for the new quality program came from the graduate medical education community. The Accreditation Council for Graduate Medical Education (ACGME) had recently implemented its Clinical Learning Environment Review (CLER) program to encourage health systems, medical centers, teaching hospitals, and other clinical settings to better engage residents and fellows in six focus areas: care transitions, duty hours and fatigue management and mitigation, patient safety, professionalism, quality improvement, and supervision. According to Hussain, during CLER visits, the ACGME representatives meet the C-suite executives. [The ACGME staff] attach a lot of importance to how the executive leadership of the hospital system This document contains privileged, copyrighted information. If you have not purchased it or are not otherwise entitled to it by agreement with HCPro, a division of BLR, any use, disclosure, forwarding, copying, or other communication of the contents is prohibited without permission. EDITORIAL ADVISORY BOARD Adrienne Trivers Product Director Follow Us Follow and chat with us about all things medical staff and credentialing Karen Kondilis Managing Editor kkondilis@hcpro.com Alpesh N. Amin, MD, MBA, MACP, SFHM Executive Director Hospitalist Program Vice Chair for Clinical Affairs & Quality Dept. of Medicine University of California, Irvine Michael Callahan, Esq. Katten Muchin Rosenman, LLP Chicago, Illinois William K. Cors, MD, MMM, FACPE Chief Medical Officer Pocono Health System East Stroudsburg, Pennsylvania Jack L. Cox, MD, MMM Senior Vice President/Chief Medical Officer St. Joseph Health Irvine, California Taylor Diefenderfer, MS-PSL Medical Staff Coordinator/Risk Coordinator Kansas Heart Hospital Wichita, Kansas Sandra Di Varco, BSN, RN, JD McDermott Will & Emery, LLP Chicago, Illinois Jeffery Jensen, DO, MPH, MBA Vice President Medical Affairs Morton Plant Hospital Clearwater, Florida Todd A. Meyerhoefer, MD, MBA, CPE, FACS Vice President Medical Affairs and Chief Medical Officer Union Hospital Dover, Ohio Sally Pelletier, CPMSM, CPCS Advisory Consultant and Chief Credentialing Officer The Greeley Company Danvers, Massachusetts Cindy Radcliffe, CPMSM Director Medical Staff Services St. Jude Medical Center Fullerton, California Jodi A. Schirling, CPMSM Alfred I. dupont Institute Wilmington, Delaware Richard A. Sheff, MD Principal and Chief Medical Officer The Greeley Company Danvers, Massachusetts Leslie Tar, MD, MPH, Esq, LLM Physician/attorney Medical Staff Briefing (ISSN: [print]; [online]) is published monthly by HCPro, a division of BLR. Subscription rate: $425/year or $765/two years; back issues are available at $25 each. MSB, 100 Winners Circle, Suite 300, Brentwood, TN Copyright 2016 HCPro, a division of BLR. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro or the Copyright Clearance Center at Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call or fax For renewal or subscription information, call customer service at , fax , or customerservice@hcpro.com. Visit our website at www. hcpro.com. Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. Opinions expressed are not necessarily those of MSB. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. 2 HCPRO.COM 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

3 October 2016 Medical Staff Briefing engages in training of residents and fellows, and how they are engaging residents and fellows in quality improvement. DMC, which is affiliated with Wayne State University and Michigan State University, has more than 1,100 residents and fellows coming through its doors. The facility decided in 2014 to distribute financial incentives among residents and fellows to improve VTE prophylaxis and stroke care, and, by extension, to drive these stakeholders engagement in quality improvement and patient safety. We thought we needed to come up with a game plan to satisfy ACGME and improve our own metrics. We realized that residents and fellows are at the forefront of taking care of patients. Without their engagement and buy-in, no matter what kind of initiative the hospital system comes up with, it is not going to be successful. CMS incentivizes hospitals, we incentivize physicians in terms of quality, and so why not residents and fellows who spend the largest amount of time with patients? We thought it made sense to pass on some of the incentivized payments over to them, Hussain says. How it works Together with its electronic health record (EHR) vendor, DMC developed a widget and embedded it in patients EHRs. The widget serves as an interactive checklist of quality measures that visually represents care gaps in real time. This was a game changer for us because it enabled us to monitor patients in real time not only for VTE but for our other core measures, says Hussain. It s really an amazing tool. DMC also developed a widget app for smartphones that residents can use to reference core measures, metrics, an anticoagulation guide for VTE, and other resources. We tell residents, This is your one-stop shop. You go here if you have a heart failure patient or you have a stroke patient and want to see which metrics count and what are the evidence-based guidelines and measures that are important for core measures, says Hussain. Residents from each of the dozen participating programs (e.g., emergency medicine, internal medicine, and family medicine) were also selected to serve as resident directors and given command of certain units at the hospital. Resident directors are chosen based on their interest in quality improvement. These directors are responsible for ensuring patients in their unit are given appropriate prophylaxis for VTE. Every day, the resident directors interact with the administrative staff, nursing leadership, physicians, and physician leadership to ensure all the metrics are met. The resident directors also review the widget daily and provide feedback to providers regarding any lapses in care. Residents are instructed to check the widget once a day, which takes about minutes, according to Hussain. If there is a gap where a core measure is not met or is pending, the resident director is responsible for getting in touch with the corresponding physician or, if necessary, for escalating the issue to the chief medical officer or chief nursing officer. We ve maxed out on our core measures. We ve reached beyond where we were supposed to go. Syed Ahmed Hussain, MD If the health system achieves 95% compliance, residents and fellows who engaged in at least one of the quality measures are eligible for financial incentives, which are awarded quarterly. Payments in the first year ranged from $300 to $4,000, depending on the resident s level of involvement. Resident directors receive higher incentive payments in recognition of their leadership and increased commitment to improving patient safety and quality despite their busy schedules, Hussain says. The results Hussain and his colleagues recently published their initial findings from the first year of the program in the Journal of Graduate Medical Education. Results were overwhelmingly strong in the first year and remain high. VTE prophylaxis, which had 80% compliance in 2013, now consistently hits 99% month after month, Hussain says. Stroke process measures also regularly reach 100% compliance. We ve maxed out on our core measures. We ve reached beyond where we were supposed to go. It s been very successful, Hussain says. We ve spent a 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or HCPRO.COM 3

4 Medical Staff Briefing October 2016 decent amount in incentive payments to residents and fellows. It s not just physicians who are responsible for the progress, though. It took a concerted effort by all those involved in the care of patients because some metrics are led by nursing or pharmacy. Therefore, DMC took a team approach to improving core measures. It takes a village, and that is what we did, says Hussain. He adds that residents and fellows have been genuinely receptive to the project and have provided positive feedback in DMC s internal GME survey. The facility sought out feedback from residents through its resident council when creating the program. In 2013, Hussain was a chief resident and vice president of the resident council, so he helped form the program from the resident s perspective. Now he is in the C-suite and can support the project from the other side. C-suite involvement in resident work and quality improvement is crucial in determining how successful programs are at an institution, he says. This buy-in is also important given the large amount of money that will be given out as incentive payments, says Hussain, who recommends ensuring the CEO, CMO, and chief financial officer are on board with the expenditures. Having the C-suite on your side will also help with entrenched physicians who are resistant to any form of change. Hussain admits there was some pushback from physicians when the program first started and that it took a lot of education to get physicians to see the merits. To win over reluctant practitioners, the program advocates targeting the medical staff society meetings, physician leadership council meetings, council of chiefs meetings, resident council meetings, and nursing meetings. Leadership s backing was especially helpful when the DMC program expanded to readmissions and hospitalacquired infections, which can be more controversial than VTE prophylaxis or stroke care. With readmissions, when you re trying to tie down attribution to a given physician, and there might be a change in practice needed, you need administrative buy-in. You need the chief medical officer or the physician advisor to be on your side and be on board with the project in order for it to be successful, Hussain says. At DMC, the effort was championed by Suzanne White, who was a pioneering leader in engaging residents and fellows in quality improvement. Without her, none of these projects would see the light of day, notes Hussain. Continuing and expanding the project DMC has continued the program beyond the first year and expanded its scope. The resident director team initially consisted of 14 individuals, but it has since grown to include 40 residents and fellows from multiple specialties. DMC is also addressing other quality improvement and patient safety issues, such as hospital-acquired infections and readmissions, Hussain says. The program now includes some metrics that CMS uses in its hospital quality star ratings program. In July, CMS released the latest star ratings for hospitals on the Hospital Compare website. If I am a patient and looking for a hospital because I am new in town, I can search for hospitals based on quality outcomes or complication outcomes from surgical procedures, or mortality, based on CMS star ratings. It is important in today s world because the patient has leverage to make their own choice based on metrics, says Hussain. The widget has also proven an effective documentation tool, he adds. Later this year, DMC will be one of the first health systems in the country to begin submitting its core measure data to CMS and The Joint Commission electronically without chart abstraction the process that requires someone to go into a chart and manually extract data. Getting started Hussain encourages other hospitals interested in bolstering engagement in quality improvement to consider an incentive-based approach. He says the best way to start is to leverage your EHR. We all have EHRs and are able to track metrics. One program does not fit all, so come up with innovative ideas to engage your residents and fellows, says Hussain. When we attend national conferences, we see different academic medical centers doing similar but different things; there is a lot of great work going on around the country. That is why I am confident that what we do here at DMC can be replicated and done in a different way at other programs in a way that suits them. H 4 HCPRO.COM 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

5 October 2016 Medical Staff Briefing Turn your application into a powerful tool A job application is the first look an employer gets at a potential employee. Along with providing the essential information an employer needs to know, it may also provide some subtle yet valuable insight into whether that candidate is a good fit for the organization. The same is true for medical staff applications. Developing a thorough application form for practitioners and a consistent application process can help prevent immediate problems, such as discriminatory lawsuits, and problems down the road, such as disruptive physicians. Uniformity in this process is very important, says Elizabeth Snelson, Esq., who provides legal counsel for medical staffs. MSPs do not want to risk forgetting a step for an applicant because doing so could be viewed as discriminatory. For example, if a female practitioner s application is handled differently than a male practitioner s, it could be argued that the female is a victim of gender discrimination. One way to avoid accidental omissions is to write down each step in the process and use it as a checklist when handling an application. Match the application with the bylaws Too often, medical staff applications do not fall in line with what is required in the medical staff bylaws, says Snelson. The two must match. Bylaws may require that certain information be collected, yet that information is not asked for on the application. An example of this is not asking about care outside of the hospital setting, such as at an ambulatory surgery center. If the bylaws state it, the application should ask whether the physician performed care outside of the hospital, and whether there were any adverse actions. On the opposite end of the spectrum, applications might overreach, asking for information that is not authorized in the bylaws. If the form says, Do you live within two miles of the hospital? and the bylaws do not require you to live within two miles, why is that on the application? It is not relevant, says Snelson. If you deny someone s application because they live four miles away, what are you going to stand on? A common overreaching question that Snelson advises against relates to economic credentialing. Ensure your organization s application does not ask a potential medical staff member to define his or her practice by referral source or to indicate how many patients he or she will refer to the hospital. Such a question suggests the hospital expects the physician to bring in a certain number of patient referrals, she says. Involving economic ties in the application process is absolutely inappropriate. When Snelson asks healthcare organizations why they have this question on their form, they usually respond, It s always been on the form. MSPs also struggle with a lack of predefined privileging criteria, which can manifest itself in a more subjective process as opposed to an objective one, according to Sally J. Pelletier, CPMSM, CPCS, advisory consultant and chief credentialing officer at The Greeley Company in Danvers, Massachusetts. Just as a well-designed application enhances your process, the development and implementation of a criteria-based privileging system provides guidance for MSPs in processing privileging requests and for medical staff leaders in making recommendations related to privileging decisions, says Pelletier. Because both facets are so important, be sure to apply the same diligence to your organization s membership criteria that you use when researching and adopting privileging criteria. Develop a realistic timeline Although it is important to maintain a consistent process, it is also critical to regularly review the application and make changes if necessary. Snelson recommends reviewing the medical staff membership application form every time the section of the bylaws pertaining to the application process is reviewed. She also recommends expanding the bylaws committee s jurisdiction to include all medical staff forms. Making this change: Ensures routine review and tracking of medical staff forms Elevates the application process from a clerical function to one that requires appropriate oversight If the form gets away from the medical staff, that is 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or HCPRO.COM 5

6 Medical Staff Briefing October 2016 where the problem comes in and the form takes on a life of its own that has nothing to do with the medical staff bylaws application process, says Snelson. You need a process that you can live with, that works for your institution, which you then follow Elizabeth Snelson, Esq. MSPs also need to be included in the review and tracking of forms because they know how the entire application process works. The MSP can advise the medical staff on what timelines will work for the application process. The staffing, software, and resources available in the medical staff services department (MSSD) will all affect how quickly an application can be processed, and if a deadline is not feasible, it is the responsibility of someone in that office to stand up and say, This process will not work. Deadlines imposed by the medical staff are a typical stumbling block, says Snelson. If an organization sets unrealistic deadlines and applications are not processed in time, accreditors will take note of this during their next site visit. An even bigger issue is if re-applicants are not processed in time, affecting current physicians memberships/privileges. Although a member of the MSSD office should speak up when timelines are too short, overly padded deadlines are no better. Do not make up a number; be real. Run through your system and see how long it takes to really process an application, says Snelson. You need a process that you can live with, that works for your institution, which you then follow. Break out the red pen A thorough application is the first step to weeding out problem physicians. MSPs need to be trained to spot red flags on applications: a piece of information that needs further investigation or information that s missing altogether. A red flag makes the MSP think, Is this practitioner being totally honest with me? Should I dig a little deeper? Common red flags include: Questionable items on a privilege form Moving around a lot Having multiple malpractice insurance carriers Having several malpractice claims Not finishing a residency or training program Having several NPDB reports Gaps in education, training, or work experience, especially unexplained gaps A red flag on an application is not always so black and white (or red), though. Listen to your gut. If necessary, dig a little deeper by going on the internet and researching the applicant. Take notes to show to medical staff leaders so they can review the information and decide whether to dig into the issue further. Missing information doesn t always signal a dishonest practitioner. Applicants make mistakes, especially when they are trying to fill out lengthy applications in the little free time they have. MSPs often struggle with incomplete applications during the process, according to Pelletier. This is why she is in favor of electronic applications, which do not allow the application to be submitted if it is not entirely filled out. MSPs may be pressured by practitioners, recruiters, or medical staff leaders to move through the application process faster. Unless an application gets deemed stat because there is a patient care need that demands the immediate approval of a practitioner, MSPs should not skip any steps in the process. Opening up the lines of communication and educating key stakeholders can help relieve some of the pressure. Create a flow chart for the credentialing process and use that as a tool to explain all of the steps, says Pelletier. A simple can help too. Let the practitioner, as well as his or her designated contact, know the application was received and what step of the process it is in. Communication about the process, including the burden on the applicant to provide information in a complete and timely manner, will help with turnaround time even communication initiated before the practitioner begins to fill out the application. Pelletier says investing extra time and resources up front will lead to a smoother process, something everyone will appreciate. A clear and concise structure eliminates confusion and guesswork on the part of the applicant, resulting in a less frustrated practitioner and ultimately a quicker process, which results in increased revenue for both the practitioner and the organization, says Pelletier. H 6 HCPRO.COM 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

7 October 2016 Medical Staff Briefing Initial Appointment Application Instructions Return to: [Hospital] Medical Staff Services Department Address City, state, ZIP Telephone number(s): or Fax number: General Instructions All information requested in this application is necessary to complete the credentialing process. This information is based on the standards for physician credentialing established by [CMS/Hospital accreditor] and [Hospital] s medical staff bylaws. Failure to provide the specific requested information and documentation will result in delays in verification and/or approval of your credentialing file. Prior to completing this application, please read and observe the following: Print legibly or type your responses. Modification to the wording or format of this form or the privilege forms will invalidate both. All questions must be answered fully and truthfully. If more space is needed, attach additional sheets. Make reference to the question being answered. See CV or résumé is not an acceptable answer. If a particular section does not apply to you, write n/a in that section. Mail or hand deliver the completed, signed application form to the medical staff services department, along with all of the requested documentation, completed forms, and any application processing fees. Make a copy of the application to retain in your files and/or computer for future use and reference. You must update the medical staff services department promptly if any information on this form changes once it has been submitted. Source: The Medical Staff Office Manual: Tools and Techniques for Success, published by HCPro, a division of BLR HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or HCPRO.COM 7

8 Medical Staff Briefing October 2016 Bipartisan Budget Act of 2015: Implications for MSPs by Patricia A. Furci, RN, MA, Esq., and Samuel J. Furci, MPA, principals at Furci Associates, LLC, in West Orange, New Jersey. They may be reached at The Bipartisan Budget Act of 2015 has many components. While it includes a raise in the nation s debt ceiling, MSPs need to be aware of the potential credentialing implications caused by the act s impending regulatory changes. The Bipartisan Budget Act excludes newly acquired, off-campus hospital outpatient departments from receiving reimbursement under Medicare s hospital outpatient prospective payment system (OPPS). After January 1, 2017, these new offcampus locations will be reimbursed under the ambulatory surgical center prospective payment system (ASC PPS) or the Medicare Physician Fee Schedule (PFS). However, there are exemptions and grandfathering provisions, so understanding the regulatory road map is most important. Under Title VI of the Act, Section 603 provides for a new Medicare payment policy for new outpatient providers. This site neutrality provision begins to address concerns that Medicare should not be paying different amounts for the same services based on the location or provider type, and that hospitals may be improperly incentivized to acquire and label physician practices and ambulatory surgery centers (ASC) as hospital outpatient departments due to higher rates available for services furnished in hospital outpatient settings. CMS oversees Conditions of Participation and Conditions for Coverage (CfC), and healthcare organizations must meet both sets of requirements to begin and continue participating in the Medicare and Medicaid programs. Medicare uses several payment systems to pay for services furnished to beneficiaries on an outpatient basis. Most often, when a Medicare beneficiary receives a service in a physician s office, Medicare pays for that service pursuant to the PFS. If that beneficiary receives the same service in a hospital setting, Medicare also pays a facility fee under the hospital OPPS. When Medicare pays both a professional fee (under the PFS) and a facility fee (under the OPPS), the total payment is typically higher than if Medicare makes just one payment to the physician under the PFS. Similarly, if a beneficiary receives a surgical service in an ASC, the Medicare payment is always less than if the beneficiary receives the same service in a hospital setting. Research from The Heritage Foundation confirms that Medicare reimburses hospital-based services and procedures, including surgeries and colonoscopies, at dramatically higher rates than reimbursement for the same procedures provided at ASCs. (The Heritage Foundation [2015, October 28]. Analysis of the Bipartisan Budget Act of ) When an ambulatory care setting is operating under a hospital license, the facility and its practitioners are subject to the same accreditation and regulatory standards as the hospital. As a result of this incentive, many hospitals have outpatient provider services off-campus, defined under Medicare regulation as no more than 250 yards from the main hospital campus. Current law provides for outpatient medical services to be reimbursed through a prospective payment system: a fixed, predetermined price for a given medical service or procedure based on a diagnostic code. Under this provision (Title VI of the Bipartisan Budget Act, Section 603), any new (i.e., after the date of enactment: November 2, 2015) providerbased hospital outpatient department that is off-campus, including physicians and other personnel, is to be reimbursed under the regular Medicare Fee Schedule (PFS) or, if eligible, under the Medicare payment system that governs ASCs which, again, is often lower than reimbursement under the OPPS. Policymakers and watchdogs such as the Medicare Payment Advisory Commission (MedPAC) have stated for years that the disparities in reimbursement are not justified and that they incentivize hospitals to acquire 8 HCPRO.COM 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

9 October 2016 Medical Staff Briefing physician practices and ASCs in order to gain a higher payment for furnishing services in a hospital setting. Most recently, there has been increasing criticism that these incentives have led to widespread vertical integration and increased Medicare expenditures. (MedPAC [2013]. Report to the Congress: Medicare and the Healthcare Delivery System ) What does all of this mean to MSPs? It means that regulatory changes are around the corner, so it is important for MSPs to know their options when it comes to ensuring compliant credentialing and privileging practices. Key factors Structure, consistency, and state law are key factors that MSPs should address in regard to credentialing and privileging ambulatory care providers see Ambulatory care credentialing in the February 2015 issue of Medical Staff Briefing. When an ambulatory care setting is operating under a hospital license, the facility and its practitioners are subject to the same accreditation and regulatory standards as the hospital. Take, for example, a large medical group that includes licensed independent practitioners and dependent practitioners. If this group is contracted with the hospital to provide ambulatory care services at off-site locations that are under the hospital license or provider number or within the hospital, and if these locations meet the requirements of the Bipartisan Budget Act as of the act s effective date, the group s practitioners must be credentialed and privileged through the hospital while following the requirements of the medical staff bylaws and related policies. (See the February 2015 Medical Staff Briefing.) It is also important to reiterate that the ambulatory care practitioners in the above example must be consistently credentialed and privileged. Privileging criteria must be objectively applied in order to meet Joint Commission standard MS Unless privileges are specifically differentiated by location or available resources, objective privileging criteria must be applied in order to meet MS , EP 3. Now let s take a situation where an off-site ambulatory care location does not meet the date of enactment (November 2, 2015) requirement under the Bipartisan Budget Act and the location is now considered not to be eligible for reimbursement as a hospital department. In this example, there are other credentialing and privileging issues for consideration. Regardless of where the particular location sits in the entity s overall organizational chart, if the location is not part of the hospital but receives Medicare reimbursement, it will still be subject to the requirements of CMS CfC. For MSPs, a review of state law is very important in determining scope of practice for each professional. In order to ensure established privileging criteria are consistently applied, one suggestion is to categorize privileges to each specific facility and confirm that they can be performed in that particular setting. It is also important to identify individuals who are not employees but who are providing patient care services in the off-site location in order to avoid overlooking services that require privileging, such as operating x-ray equipment, interpreting x-rays, and administering local anesthesia. Even registered nurse first assistants, physician assistants who work with a particular surgeon, or others (e.g., physical therapists, audiologists, or any other technician assisting a physician) require credentialing and privileging. Privileges for x-rays are particularly important given the expansion of pain management. Further, physicians who are reading and interpreting films must have the privileges to do so in their specific facility or location. If your hospital radiologists are reading and interpreting films in an off-site location that is not part of the hospital, the radiologists also must be credentialed through the entity for which they are practicing and not merely the hospital. This means having a credentialing structure and documentation as well as privileging criteria for the specific entity or group of entities that are not part of the hospital. Conclusion For MSPs, a review of state law is very important in determining scope of practice for each professional. MSPs should also review this matter with their medical staff leadership, legal counsel, and regulatory 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or HCPRO.COM 9

10 Medical Staff Briefing October 2016 compliance staff. While decisions will likely be financially driven, it is important for MSPs to articulate the importance of lead time for implementing the resulting changes that may be necessary for credentialing and privileging. This of course includes establishing systems required for determining current clinical competence. CMS, which will be responsible for implementation, may seek to stretch its authority and add further limitations that effectively freeze the size and scope of the existing location, according to the Healthcare Financial Management Association (HFMA). Thus, this limitation technically applies only to those entities not meeting the definition of campus, although how a provider has positioned a location as on- or off-campus with CMS will be just as important. (HFMA) The limitation applies only to items and services furnished by a hospital department. Under those same regulations (Title VI of the Bipartisan Budget Act, Section 603), an entity is considered a hospital department (as opposed to freestanding or a provider-based entity) if it is, among other things, furnishing services of the same type as those furnished by the main provider. As such, this change applies to physician and ASC services of the same type as those furnished by a hospital. (HFMA) Healthcare organizations should also be on the alert for guidance from CMS interpreting and implementing Section 603 as it relates to the ability to create new off-campus provider-based locations even if not reimbursable under the OPPS. CMS guidance may also address the ability to include such locations on a hospital s Medicare cost report (a key requirement for child site eligibility under the 340B Drug Pricing Program). Look for further clarification regarding the scope of the grandfathering provision as well as the impact of hospital changes of ownership and other transactions that involve the acquisition of existing provider-based hospital locations (e.g., associated with another tax identification number or Medicare provider number/ CMS Certification Number) on that grandfathering. (HFMA) The end results are likely to be more procedures, more structural changes for credentialing, more privileging criteria, and more criteria for determining current clinical competence in nonhospital department settings. Buckle up, everybody! H Exciting updates: More content, tools, and news at your fingertips! The challenges healthcare professionals tackle each day don t wait for solutions, and neither should you. That s why Medical Staff Briefing is transitioning to a more frequent and robust publishing model this fall and expanding into a Credentialing Resource Center membership. Your updated member benefits gain you access to content and tools on the Credentialing Resource Center (CRC) with new resources added weekly to the website ( Plus, as a CRC member, you gain instant access to over 300 clinical privilege white papers, core privileging forms, the Medical Staff Talk forum, our sister publication Credentialing Resource Center Journal, and the daily e-newsletter Credentialing Resource Center Daily. If you are already a CRC member, you will continue to receive the news and analysis you ve come to rely on, plus expanded member benefits coming this fall. To help readers keep tabs on available content, we will announce new articles in Credentialing Resource Center Daily, CRC s daily e-newsletter for medical staff leaders and MSPs. At the end of each month, we ll roll the corresponding weekly articles into a digital issue of Medical Staff Briefing that mirrors the current format. As a member of CRC, you can continue to download and print high-quality PDFs of the current issue, as well as several years of back issues of Medical Staff Briefing, directly from CRC s website. We re looking forward to delivering your medical staff guidance in a more timely, efficient, and convenient manner. Stay tuned for additional details as we near implementation. In the meantime, feel free to contact Editor Karen Kondilis at kkondilis@hcpro.com with any questions. 10 HCPRO.COM 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

11 October 2016 Medical Staff Briefing Credentialing: An evolving primate by Kathleen Tafel, credentialing and privileging consultant Credentialing has evolved from a clerical task to a profession that requires expertise in the interpretation of accrediting standards and state and federal regulations. Credentialing professionals have become the source of truth for medical executive committees, credentials committees, and governing boards. Many MSPs view personal success as being a professional who is recognized at the table of many leadership meetings. Now, another facet of evolution for the credentialing professional has emerged: revenue validation. Revenue validation is the result of timely credentials file processing and the subsequent impact on the organization s revenue. Credentialing professionals traditionally weigh their personal value to the organization according to their depth of knowledge; the hospital, though, may focus on how quickly a file is processed. Consequently, how we evaluate our personal success as MSPs now includes productivity margins. Credentialing professionals need to parse leadership s view on credentialing in advance by developing a list of nuances and discussing them in the interview phase. If productivity for MSPs is defined by the organization as number of files processed, then levels of productivity may be defined differently at a hospital medical staff office versus a centralized verification office. What is viewed as being productive increases exponentially if you are credentialing 3,400 physicians and allied health professionals every two to three years as opposed to credentialing 600 physicians and allied health professionals. A hospital medical staff may define success as an MSP processing 10 new files a month, whereas in a network setting, an MSP is considered to be successful if he or she processes 10 new files in a week. As more credentialing professionals transition from smaller staffs to larger network responsibilities, they must also transition their personal expectations of productivity to match the network s expectations. MSPs thinking about transitioning to network environments need to evaluate the structure of the proposed or existing credentialing environment, as it may differ significantly from the individual hospital setting. For example: What is the staff to file ratio? What are the current productivity statistics? Is there a leadership pyramid that defines the productivity margins? If so, how is the unavoidable delay time (delay in query responses) accounted for in those margins? Who has the autonomy to make changes to the productivity structure? How are deficits in the credentialing software accounted for in the productivity structure? Do MSPs report these statistics on number of files processed to physician leadership (as they would in a hospital setting) or to administrative leadership? How well-versed are the leaders in credentialing and privileging? In a larger network setting, identifying these issues to administrative leadership may seem petty or insignificant if the formula for productivity does not include such nuances. Credentialing professionals need to parse leadership s view on credentialing in advance by developing a list of nuances and discussing them in the interview phase. This will help the MSP determine whether the leadership is aligned to the MSP s values and if the network s and department s goals are aligned with each other. If leadership has never thought about those issues, MSPs might then wonder how much autonomy they will have to make the necessary changes. Credentialing requires a level of professional insight into collected data to provide a substantial summary to a wide variety of individuals who will determine if an applicant is qualified and competent to serve the patient population. Credentialing professionals should not be equated to assembly line workers. Passionate credentialing professionals are not subjectively concerned with turning out files. They are concerned 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or HCPRO.COM 11

12 Medical Staff Briefing October 2016 about producing files of quality and substance. To produce quality work and meet productivity standards in network settings, there must be a foundational synergy between the credentialing professionals and the immediate and senior leadership. Successful credentialing teams have a contemporary knowledge base of best practices, and the team works in tandem with those practices. The best practices are vetted by leadership and agreed upon as the gold standard of processing. When all individuals involved in processing are aligned, there is a clearly defined productivity margin that is realistic and derived through the knowledge and nuances of how credentialing files are processed. Yes, credentialing is evolving, and as credentialing professionals, we too will evolve and add more depth and substance to our passion. If you are considering a transition from a hospitalbased credentialing career to a network-based career, consider obtaining information that you will need to be successful in your endeavor, such as: 1. Is the direct senior leadership a physician or individual who has knowledge of how a file is processed and understands the nuances of delayed files? 2. Are your counterparts in privileging and in the revenue department knowledgeable and supportive about credentialing best practices? Are they aligned and focused toward one goal? Do they work synergistically as a team or are they competitive? 3. What are the bylaws of the network medical staff? How do they differ from those of a smaller hospital? 4. Are there clearly defined productivity standards in place, or will you be developing those standards? Has senior leadership made recommendations on the standards? 5. Is the team synergistic, or are there systemic problems? If there are problems, what has derailed the solutions? Is there a timetable and business plan to implement those solutions? Yes, credentialing is evolving, and as credentialing professionals, we too will evolve and add more depth and substance to our passion. We should not let productivity become our sole focus. Productivity is instead the downstream effect of a solid foundation composed of gold standards for credentialing and a synergistic team whose senior leadership embraces the root of what credentialing professionals are passionate about: ensuring patients have the best possible care providers. Until next time, believe in what you do and do what you believe. H Call for medical staff leaders To ensure that the Credentialing Resource Center s library of Clinical Privilege White Papers stays relevant and robust, we re looking for medical staff leaders (physicians and advanced practice providers) to join our dedicated advisory board. The board presents a unique platform for medical staff leaders and MSPs to share expertise with colleagues, keep current on developments in their respective fields, and gain recognition for their contributions. In return for their service, active and engaged advisory board members will see their name, credentials, and affiliations featured in the masthead that concludes each Clinical Privilege White Paper and will receive a complimentary membership to the Credentialing Resource Center. Advisory board duties may include the following: Review relevant white papers Participate in occasional calls with other board members and/or the project editor to discuss and shape the trajectory of the white paper library Connect the project editor with subject matter experts who would be interested in being interviewed for procedure papers Submit suggestions for future white paper topics and/ or direct the project editor to notable developments in the field To apply for board membership or to request additional information about this opportunity, please CRC Editor Delaney Rebernik at drebernik@hcpro.com. 12 HCPRO.COM 2016 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or