The Credentialing School: Ambulatory and Managed Care

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1 Join us for the most comprehensive, hands-on training available in the industry today! Pathway to Knowledge For individuals responsible for credentialing and enrollment in ambulatory healthcare settings, physician practices, managed care and healthcare networks. What Can You Expect? Up to five days of intensive training Certificate of completion Timely, Convenient, Affordable Experienced, nationally-respected faculty Approved by NAMSS for up to 38 CEUs Contact us today for more information, or to set up a corporate on-site program!

2 What is The Credentialing School? This course is designed to provide intensive, hands-on education and training for individuals in ambulatory and managed care organizations who have little or no experience or training in the areas of credentialing and enrollment. Why a Credentialing School? Many organizations are not able to hire trained, experienced and certified staff to carry out credentialing and enrollment activities due to the high demand in health care. Building a strong credentialing process assures adequate information for informed employment, affiliation and enrollment decisions. Credentialing verifies that physicians and other healthcare practitioners meet standards as determined by an organization. Credentialing includes review of license, experience, certification, education and training, malpractice coverage and history. While not a required process in all ambulatory and managed care settings, credentialing has become an industry standard. A well-structured program reduces risk to the organizations hiring and contracting with nonqualified practitioners. Ambulatory care organizations and physicians can build their enrollment processes on credentialing data and improve the quality and timeliness of enrollment and affiliation. Course Objectives Upon completion of this Course, students should: Understand the key components of best practice credentialing Understand the importance of credentialing Be able to relate credentialing activities with payor enrollment Be able to process a credentialing application including primary source verification and requests for additional information Utilize critical thinking skills in managing credentialing processes, identifying red flags, and assessing information Apply principles of best practice credentialing in accordance with applicable standards and regulations Serve as a critical resource to the organization 2

3 Who Should Attend? Individuals with responsibility for credentialing and enrollment activities in: Ambulatory healthcare clinics Physician offices Multi- and single-specialty group practices Healthcare networks Managed care companies Urgent or Immediate care centers And others who would benefit from understanding the basic components of credentialing and enrollment in ambulatory and managed care settings including: Practice Managers, COO s, Administrators, Executive Directors Medical Directors, Chief Medical Officers Chief Financial Officers Compliance Officers Information Systems Managers Quality Directors and Managers Physician Shareholders You Should Consider Attending if: 1. your organization does not have a structured, documented, functional credentialing process, or 2. the individuals in your organization have learned all they know from on the job training from someone who learned all they knew from on the job training, or 3. your physicians are starting work before they are enrolled with payors and able to bill for services, or 4. you do not have staff that knows how to verify education and training, whether or not to do criminal background checks, or what the DEA schedules mean, or 5. you and your staff want to meet others with the same challenges, concerns, and needs, or 6. you have been unable to find adequate, comprehensive, how to resources about credentialing, enrollment and delegation in ambulatory and managed care, or 7. your physicians are rebelling about completing forms and providing the same information over and over and over, or 8. you aren t sure you are doing the right things the right way, and / or 9. you need to talk about what keeps you awake at night with certified professionals who have broad experience, knowledge of best practice, and real world answers! 3

4 Curriculum Highlights Overview and Introduction - What is it, and why do we do it? The basics include... Differences between credentialing, privileging and enrollment History and background of credentialing Case law related to credentialing In the ambulatory and managed care settings Credentialing Activities without a solid basis, you will pay the price! Practitioners and providers who are credentialed Structure to support credentialing activities Credentialing plan, program and policies Credentials file - paper or electronic Credentialing software Credentialing information as the basis for enrollment The Credentialing Process step1, step 2, step 3, Pre-application Application and attestation Gathering data and information / Primary source verification Review and action Recredentialing Maintenance and ongoing activities Enrollment and Participation / Hospital Affiliation it s where the money is, so we need to get it right! Parameters and key elements Contracts, requirements of payors Hospital affiliation Enrollment process / tracking status Currency of information in file, access and confidentiality Allied Health Credentialing beyond physician credentialing What s different Verification and information / sources Options for review and decision process Common issues Credentials Verification Organizations - all CVOs are not the same Accreditation / certification 120 day rule Customization Role in obtaining application Use for recredentialing Delegated Credentialing - may be beneficial Parameters NCQA and TJC requirements Delegation agreement Oversight / delegation audit Issues and pitfalls 4

5 Curriculum Highlights Accreditation and Regulatory Organizations - and the Standards and Requirements Who, why, how applicable Organizations and applicable standards NCQA National Committee for Quality Assurance CMS Centers for Medicare and Medicare Services URAC Utilization Review Accreditation Commission AAAHC Accreditation Association for Ambulatory Health Care TJC The Joint Commission Federal statutes State requirements Roles, Responsibilities, Interactions and Customer Service we re all in this together Recruitment Contract development Physician service and support Access to information and confidentiality Making it all work Handling difficult situations Site Visits - surveying the physician office, doing it or preparing for it Who, when, how, what and where Office-site criteria Medical Record keeping criteria Improvement actions, evaluating effectiveness Monitoring patient complaints Facility Credentialing / Organizational Providers an NCQA standard Scope - types of providers Key elements Plan, policy and procedure, criteria Credentialing or quality Health services contracting Monitoring performance issues Meeting Management and the Credentials Committee if it s not documented, it s not done Preparation Use of logs Minutes and meeting follow-up Effective meeting skills Responsibilities of members, chair and support staff Confidentiality Tools of the Trade sharpen them! Assessing the effectiveness and productivity of credentialing activities Credentials File audit tool Critical thinking analysis, synthesis and evaluation Professional / career development National Association Medical Staff Services State associations Resources 5

6 Faculty The Credentialing School: SHERYL DEUTSCH, CPCS Sheryl has developed and presented programs in the areas of credentialing, meeting management, leadership, member services, peer review, and quality / performance improvement in managed care, physician groups and hospital settings. Prior to founding Quality Management Options, she held the position of Corporate Director of Quality Services for Lincoln National, a multi-line insurance carrier with approximately five million members served in multi sized markets offering all types of managed care products. She is: Certified by the National Association Medical Staff Services with 30 years experience in healthcare and 18 years as a registered nurse An author: Credentialing Handbook Editor of Medical Staff Management Forms Policies and Procedures President of Quality Management Options LLC, a consulting firm established in 1992, located in Colorado Springs, Colorado Co-founder of, offering educational resources for healthcare professionals CHRISTINA GILES, CPMSM, MS Chris has presented nationally to state and local associations on multiple topics, such as accreditation preparation, credentialing, privileging, medical staff office management, physician leadership and orientation, and board of trustees roles and responsibilities. She is: An advisor to multiple medical staff publications (Credentialing Resource Center and Credentialing and Peer Review Legal Insider.) Certified by NAMSS as CPMSM, serves as NAMSS Instructor, served on NAMSS Education Council and board and was a founding member of the Massachusetts Association Medical Staff Services An author & editor for The Medical Staff Services Handbook: Fundamentals and Beyond and contributing editor to: Health Care Credentialing: A Guide to Practical Innovations Active member of The Credentialing Forum Past surveyor for NCQA s CVO Certification program President of Medical Staff Solutions, a consulting firm located in Nashua, New Hampshire established in 1996; Chris has over 30 years experience in medical staff administration. GUEST FACULTY Guest faculty may be invited to participate in specific topic discussions, and will vary based on course location. The guest faculty will be selected from leadership positions in credentialing and other aspects of healthcare management. 6