I. Purpose The purpose of this Policy and Procedure is to establish the process including written guidelines and standards for the credentialing and re-credentialing of all clinicians defined in this policy. Also, to assure compliance for credentialing providers in adherence to standards enacted by the National Committee for Quality Assurance (NCQA), and required by third party payers. Lastly, to ensure that processes include nondiscriminatory review and credentialing, including monitoring and audits of credentialing files. II. III. IV. Scope All clinicians participating in Ochsner Physician Partners. Definitions A clinician is defined as: 1. Physician (MD or DO); 2. Podiatrist (DPM). Policy Statements It is the policy of Ochsner Physician Partners to assure compliance for credentialing providers in adherence to standards enacted by the National Committee for Quality Assurance (NCQA), and required by third party payers. All Ochsner Physician Partners (OPP) clinicians must meet the minimum eligibility and credentialing criteria and performance standards at the time of initial credentialing and maintained continuously. V. Procedures/Standards and Roles & Responsibilities 1. Time Limits - Time limits referred to in this Policy, the Bylaws and related policies and manuals are advisory only and are not mandatory, unless it is expressly stated. Medical Staff leaders will strive to be fair under the circumstances and to comply with the Page 1 of 14
provisions of the Health Care Quality Improvement Act of 1986, 42 U.S.C. Credentialing Committee ion 11101 et seq. ( HCQIA ). 2. Confidentiality a. All professional review activity and recommendations will be strictly confidential. Any breach of confidentiality may result in appropriate sanctions. b. No disclosures of any such information(discussions or documentation) may be made outside of the meetings of peer review committees, except: i. to another authorized individual and for the purpose of conducting professional review activity; ii. (a)as authorized by a policy; or iii. as authorized, in writing, by legal counsel. c. Credential files are confidential and maintained in locked file cabinets with restricted access. Electronic files will require security access. d. Access to the Credentialing/Re-credentialing documents is limited to the OPP credentialing staff, the OPP Medical Director, and the OPP Assistant Medical Officer. Exceptions to this rule must be approved by the OPP Medical Director. e. Documents in these files may not be reproduced or distributed. An exception is made for confidential peer review and credentialing purposes consistent with the law. f. All documents containing practitioner specific information are destroyed at time of disposal. g. Per contractual agreement, credential files may be reviewed by contracting health plan representatives with a current confidentiality statement on file with the Credentialing Department. 3. Qualifications Threshold Eligibility Criteria a. To be eligible to apply for initial appointment or reappointment the clinician must, as applicable: i. have an unrestricted license to practice in the State of Louisiana and in any other state where ii. license(s) was granted; iii. hold a license which is not currently nor has been subject to any probationary terms, revocation or suspension or conditions not generally applicable to all licensees; Page 2 of 14
iv. where applicable to their practice, have a current, unrestricted DEA registration and state controlled substance license; v. have current, and maintains uninterrupted valid professional liability insurance coverage in a form and in amounts satisfactory to the OPP; vi. have never been convicted of Medicare, Medicaid, or other federal or state governmental or privatethird-party payer fraud or program abuse, nor have been required to pay civil monetary penalties forthe same; vii. have never been, and not currently be, excluded or precluded from participation in Medicare, Medicaid, or other federal or state governmental health care program; viii. have never had Medical Staff appointment, clinical privileges, or status as a participating provider denied, revoked, or terminated by any health care facility or health plan for reasons related to clinical competence or professional conduct; ix. been convicted of, or entered a plea of guilty or no contest, to any felony; or to any misdemeanor relating to insurance or health care fraud, abuse, violence; or misdemeanor relating to controlled substances or illegal drugs within 10 years of date of application; x. demonstrate recent clinical activity in their primary area of practice during at least two of the last four years; and xi. (for physicians and podiatrists, at initial appointment only) have successfully completed a residency training program approved by the Accreditation Council for Graduate Medical Education or the American Osteopathic Association in the specialty in which the applicant seeks clinical privileges, or a podiatric surgical residency program accredited by the Council on Podiatric Medical Education of the American Podiatric Medical Association; 4. Waiver of Threshold Eligibility Criteria a. Waivers of threshold eligibility criteria will not be granted routinely. b. No one is entitled to a waiver. c. An application from an applicant who does not meet the threshold criteria for appointment or reappointment will not be processed unless the Operating Committee has granted the requested waiver. Page 3 of 14
d. A request for a waiver will only be considered if the applicant provides information sufficient to demonstrate that his or her qualifications are equivalent to, or exceed the criterion in question and that there are exceptional circumstances that warrant a waiver. e. The Credentialing Committee may consider supporting documentation submitted by the applicant and any relevant information from third parties. f. The Credentialing Committee will forward its recommendation, including the basis for such, to the Operating Committee. g. The Operating Committee s determination regarding whether to grant a waiver is final. h. A determination not to grant a waiver is not a denial of appointment and the applicant who requested the waiver is not entitled to a hearing. i. A determination to grant a waiver in a particular case is not intended to set a precedent. j. A determination to grant a waiver does not mean that appointment will be granted; only that processing of the application can begin. k. No Entitlement to Appointment l. No one is entitled to receive an application, be appointed or reappointed to the OPP merely because he or she: i. is licensed to practice a profession in this or any other state; ii. is a member of any particular professional organization; iii. has had in the past, or currently has, OPP appointment or privileges at any Ochsner hospital or health care facility; or iv. is affiliated with, or under contract to, any managed care plan, insurance plan, HMO, PPO, or other entity. m. Nondiscrimination: i. No one will be denied appointment, nor shall there be any discrimination, on the basis of gender, race, creed, age, disability, sexual orientation, marital status, military reserve status, national origin, for acts within the scope of a provider s state license (solely on the basis of that license or certification), or provision of care/services to high-risk populations or patients with conditions that require costly treatment. ii. OPP Network Development and Credentialing Sub-Committee members annually sign a statement affirming that they do not discriminate. Page 4 of 14
5. Clinician Provider Rights and Responsibilities a. The Credentialing Specialist shall notify the clinician when information obtained during the initial credentialing or recredentialing process varies substantially from the information originally submitted; and/or if there are omissions in the information provided. b. The Credentialing Specialist shall report any discrepancies or omissions to the OPP Medical Director and/or Assistant Medical Director. c. The Medical Director,Assistant Medical Director, or designee may contact the clinician to discuss and request clarification of the omission or discrepancy. d. The clinician shall have five (5) calendar days to respond to a request for clarification. e. Clarifications must be provided by the clinician in writing (which can include electronic mail). f. The Credentialing Specialist shall document all telephone conversations via a memo to the appropriate credentialing file. g. The clinician has the right to review information submitted to the Credentialing Department. h. With 24 hours notice and during regular business hours, the clinician may review the information contained in his/her credentialing file. i. The clinician may not review peer references or recommendations. j. The clinician shall submit any amendment or correction, in writing (electronic mail is also acceptable), to the Credentialing Department within 10 days of notification or in-person review. k. The Credentialing Specialist shall date stamp the information received and file in the clinician s credentials file. l. The clinician has the right to request an update as to the status of his/her initial credentialing or re-credentialing application. m. These rights shall be communicated via the application packet cover letter and OPP Policy and Procedure manual. n. The clinician is responsible to immediately report any change of status in the information maintained in his/her credential file to the Credentialing Department. o. A leave of absence of up to six months must be requested in writing to the Medical Director, stating the beginning and ending dates of the leave and the Page 5 of 14
reasons for the leave. Except in extraordinary circumstances, this request will be submitted at least 30 days prior to the anticipated start of the leave p. A clinician with a break in service of 30 or more calendar days must notify the Medical Director if the reason for such absence is related to their physical or mental health or otherwise to their ability to care for patients safely and competently. q. Leaves of absence are matters of courtesy, not of right. In the event that it is determined that an r. individual has not demonstrated good cause for a leave, or where a request for extension is not granted, or where reinstatement is denied for reasons other than professional competence or conduct, the determination will be final, with no recourse to a hearing and appeal. s. Under such circumstances, the Medical Director may trigger an automatic medical leave of absence. t. Individuals requesting reinstatement will submit a written summary of their professional activities during the leave and any other information that may be requested by the OPP. u. Requests for reinstatement will then be reviewed by the Medical Director. v. If a favorable recommendation on reinstatement is made, the individual may immediately resume clinical practice. w. However, if any of the individuals reviewing the request have any questions or x. concerns, those questions will be noted and the reinstatement request will be forwarded to the Credentialing Committee and the Operating Committee. If any request for reinstatement is not granted for reasons related to clinical competence or professional conduct, and if a report to the National Practitioner Data Bank is determined to be required, the individual will be entitled to request a hearing and appeal. y. If an individual s current appointment is due to expire during the leave, the individual s appointment will expire at the end of the appointment period, and the individual will be required to apply for reappointment upon his/her return from leave. 6. PROCEDURE INITIAL CREDENTIALING a. Requests for membership in OPP are reviewed by the OPP Medical Director and/or the Assistant Medical Director for network panel needs. Page 6 of 14
b. If clinician holds current privileges at an Ochsner or affiliated hospital, clinician is considered credentialed for OPP. c. If clinician does not hold current privileges at an Ochsner or affiliated hospital, an application packet is sent to the clinician and includes, but is not limited to: i. Cover letter with instructions, application, and additional items needed for credentialing and notification of rights. d. Upon receipt of a completed application packet, the Credentialing Specialist shall conduct a preliminary review of the application for completeness. e. If additional/clarifying information is required, if any questions are left blank, or if any required documents are missing, the application is considered incomplete and will not be processed until the application packet is complete. f. The Credentialing Specialist will ask the applicant to provide in writing the missing/clarifying information. g. The applicant is responsible to submit the requested/missing information to the Credentialing Specialist within thirty (30) calendar days. Any application that continues to be incomplete 30 days after the applicant has been notified of the additional information required, the application will be deemed to be withdrawn. h. If the Credentialing Specialist determines the applicant meets the Physician/Clinician Credentialing Eligibility Criteria and that the application packet is complete, the Credentialing Specialist shall initiate the credentialing and primary source verification process. i. Primary Source verification and timelines i. Primary source verification of information begins as soon as the application appears complete. ii. Primary source verifications and applications must be completed and/or dated within NCQA prescribed timeframes (180 calendar days unless otherwise noted). iii. All primary source verification is conducted in accordance with current year National Committee on Quality Assurance (NCQA) standards and guidelines. iv. All documents and primary source verifications obtained shall be date stamped with identification of staff performing the verification noted. v. For electronic verification, the as of date generated by the verification source is utilized as the verification date. Page 7 of 14
j. The initial credentialing process includes primary source verification (PSV) and/or review of the following: i. Current state professional license (PSV required) ii. Verification obtained by direct confirmation from the appropriate Louisiana or Mississippi licensing agency, if applicable. iii. Other active state licenses may be verified with the appropriate states licensing board, as required. iv. CDS license k. Clinicians who are not ordering/prescribing controlled substances, must state this in writing. l. Practitioners must demonstrate ongoing Professional Competency, as demonstrated through current Board Certification in their designated specialty Board or Board eligible with plans to pass their boards within two years. m. If greater than two years and not Board certified, then meets the requirements outlined in the OPP Professional Competency Policy. n. Board certification, completion of residency and/or graduation from medical school shall be verified by one of the following methods (PVS required): i. Board certification: 1. Directly from the American Board of Medical Specialties (ABMS) or its member boards; 2. CertiFACTS Online; or 3. American Medical Association (AMA) ephysician Profiles or AMA Masterfile. o. Verification of internship, residency and fellowship confirmation may be obtained: i. Directly from the institution(s) where the post graduate medical training was completed; ii. From the AMA Master file (must state verified to meet the standard) p. Verification of medical/professional school completion shall be obtained: i. Directly from the medical/professional school; ii. From the AMA Masterfile, or iii. From the Education Commission for Foreign Medical Graduates (ECFMG). 1. Graduates of foreign medical schools located outside the United States and Canada must present evidence of certification by the ECFMG or successful completion of a fifth pathway, or successful Page 8 of 14
passing of the Foreign Medical Graduate Examination in the Medical Sciences (FMGEMS). 2. If the AMA Masterfile is used as training verification, it must state verified to meet this standard. q. Work History i. Work History verification of relevant clinical work history for the last ten years (or from the time of licensure if less than ten years) is required. Primary source verification of work history is required. ii. The CV or application must include the beginning and ending month and year for each position in the practitioner s employment experience. iii. Any gaps must be clarified in writing. This document/statement will be filed in the Practitioner s Confidential Credentials File. r. Current, adequate malpractice insurance i. Professional liability insurance coverage and the amounts of coverage may be verified through the liability carrier. ii. The liability coverage must be current, and meet the requirements of $100 thousand per claim and $300 thousand annual aggregate, or PCF participation if coverage is only $100k/300k. iii. Carrier must be licensed in the state of Louisiana and/or Mississippi. s. Professional liability claims history (PSV required) i. Malpractice history shall be obtained from the liability insurance carrier(s) and the National Practitioner Data Bank (NPDB). t. Application for membership i. Each clinician shall complete the appropriate credentialing application. ii. The National Practitioner Data Bank (NPDB) shall be queried and the resulting report(s) included in the credential file. iii. The most recent report available to indicate Medicare and Medicaid sanctions shall be queried and the findings noted in the credential file. u. Credentialing Committee Review and Determination i. The verified file is submitted to the OPP Network Development and Credentialing Sub-Committee for review, determination and recommendation to the OPP Operating Committee for final determination. Page 9 of 14
ii. The OPP Network Development and Credentialing Sub-Committee will receive and review the credential file of any clinician whose file contains one or more of the elements qualifying the file as with issues. iii. The appropriate OPP leader (OPP Medical Director or OPP Assistant Medical Director) has the authority to determine that a credential file is Clean and to electronically sign off on the file as complete and approved. iv. The OPP Network Development and Credentialing Sub-Committee consider the application and may approve the application, deny the application or request additional information. v. The OPP Medical Director and/or Assistant Medical Director shall provide the decision to the applicant in writing. A copy will be forwarded to the Credentialing Department. vi. If the clinician credentialing is denied by OPP, OPP Medical Director and/or OPP Assistant Medical Director shall provide the decision to the clinician in writing. vii. A copy will be forwarded to the Credentialing Department. 7. The Operating Committee a. The Operating Committee may approve actions on appointment, reappointment if there has been a favorable recommendation from the Credentialing Committee and there is no evidence of any of the following: i. a current or previously successful challenge to any license or registration; an involuntary termination, limitation, reduction, denial, or loss of appointment or privileges at any other hospital or other entity; or ii. an unusual pattern of, or an excessive number of, professional liability actions resulting in a final judgment against the applicant. b. Any decision reached by the Operating Committee to appoint will be effective immediately. c. Upon receipt of a recommendation of the Credentialing Committee for appointment the Operating Committee may: i. grant appointment as recommended by the Credentialing Committee or ratify the appointment granted by the Operating Committee, as appropriate; or Page 10 of 14
ii. refer the matter back to the Credentialing Committee or to another source inside or outside the OPP for additional research or information; or iii. Disagree with or modify the recommendation. d. If the Operating Committee disagrees with a favorable recommendation of the Credentialing Committee, it should first discuss the matter with the chair of the Credentialing Committee. e. If the Operating Committee s determination remains unfavorable, the Medical Director will promptly send special notice that the applicant is entitled to request a hearing. f. Any final decision by the Operating Committee to grant, deny, revise, or revoke appointment is disseminated to appropriate individuals and, as required, reported to appropriate entities, including, as applicable, the NPDB or appropriate state licensure board. 8. Responsibilities a. Responsibility for the review and revision of this policy lies with the OPP Network Development and Credentialing Committee. 9. Re-credentialing Process: a. Reappointment will be for a period of not more than two years. Up to one hundred and eighty (180) calendar days prior to the end of the two (2) year initial credentialing period, the Credentialing department shall send the clinician an application for re-credentialing which is used to update the credentials information. b. All terms, conditions, requirements, and procedures relating to initial appointment will apply to continued appointment and clinical privileges and to reappointment. c. An application for reappointment will be furnished to Members at least four months prior to the expiration of their current appointment term. d. A completed reappointment application must be returned to the Credentialing Office within 30 days of receipt. e. Failure to submit a complete application at least 3 months prior to the expiration of the Member s current term may result in automatic expiration of appointment at the end of the appointment term. Page 11 of 14
f. The application will be reviewed by the credentialing staff to determine that all questions have been answered and that the Member satisfies all threshold eligibility criteria for reappointment. g. The credentialing staff will oversee the process of gathering and verifying relevant information and verifies through primary source verification the information that is subject to change. h. The credentialing staff will also be responsible for confirming that all relevant information has been received. i. If the Credentialing Committee or Operating Committee is considering a recommendation to deny reappointment or to reduce clinical privileges, the committee chair will notify the Member of the general tenor of the possible recommendation and may invite the Member to meet prior to any final recommendation being made. j. Prior to this meeting, the Member will be notified of the general nature of the information supporting the recommendation contemplated. k. At the meeting, the Member will be invited to discuss, explain, or refute this information. A summary of the interview will be made and included with the committee s recommendation. l. This meeting is not a hearing, and none of the procedural rules for hearings will apply. m. The Member will not have the right to be represented by legal counsel at this meeting. 10. Automatic Relinquishment a. Any action taken by any licensing board, professional liability insurance company, court or government agency regarding any of the matters set forth below, or failure to satisfy any of the threshold eligibility criteria, must be promptly reported to the Medical Director. b. An individual s appointment will be automatically relinquished, without right to hearing or appeal, if any of the following occur: i. Licensure: Revocation, probation, expiration, suspension, or the placement of conditions or restrictions on an individual s license. ii. Controlled Substance Authorization: Revocation, expiration, suspension, or the placement of conditions or restrictions on an individual s DEA or state controlled substance authorization. Page 12 of 14
iii. Insurance Coverage: Termination or lapse of an individual s professional liability insurance coverage, or other action causing the coverage to fall below the minimum required by the Hospital. iv. Medicare and Medicaid Participation: Termination, exclusion, or preclusion by government action from participation in the Medicare/Medicaid or other federal or state health care programs. v. Criminal Activity: Indictment, conviction, or a plea of guilty or no contest pertaining to any felony, or to any misdemeanor involving (I) controlled substances; (ii) illegal drugs; (iii) Medicare, Medicaid, or insurance or health care fraud or abuse; or (iv) violence. c. An individual s appointment will be automatically relinquished, without entitlement to a hearing and appeal, if the individual fails to satisfy any of the threshold eligibility criteria or perform his or her responsibilities. d. Situations involving the expiration of a medical license, controlled substance authorization (DEA or state) or a conviction or plea of guilty pertaining to any misdemeanor involving the use of alcohol will be evaluated on a case-by-case basis. e. Automatic relinquishment will take effect immediately upon notice to the OPP and continue until the matter is resolved and the individual is reinstated. f. If the underlying matter leading to automatic relinquishment is resolved within 90 days, the individual may request reinstatement. g. Failure to resolve the matter within 90 days of the date of relinquishment will result in an automatic resignation from the Medical Staff. h. Requests for reinstatement will be reviewed by the Medical Director. If all these individuals make a favorable recommendation on reinstatement, the individual may immediately resume clinical practice. i. This determination will then be forwarded to Credentialing Committee for ratification. j. If, however, any of the individuals reviewing the request have any questions or concerns, those questions will be noted and the reinstatement request will be forwarded to the Credentialing Committee for review and recommendation. 11. Operating Committee Action a. Final Decision of the Operating Committee: Page 13 of 14
i. The Operating Committee will take final action within 30 days after it (i) considers the appeal as Review Panel, (ii) receives a recommendation from a separate Review Panel, or (iii) receives the Hearing Panel s report when no appeal has been requested. b. Consistent with its ultimate legal authority for the operation of the Hospital and the quality of care provided, the Operating Committee may adopt, modify, or reverse any recommendation that it receives or refer the matter for further review. c. The Operating Committee will render its final decision in writing, including the basis for its decision, and will send special notice to the individual. A copy will also be provided to the President of the Medical Staff. d. Except where the matter is referred by the Credentialing Committee for further review, the final decision of the Operating Committee will be effective immediately and will not be subject to further review. 12. Maintenance of credentials a. The following credentials shall be kept current at all times: i. Louisiana or Mississippi professional licenses (updated prior to or at time of expiration from a primary source); ii. DEA license with Louisiana or Mississippi address. iii. CDS license. iv. Current liability insurance coverage certificate; v. Appropriate Medical Boards, if applicable. Page 14 of 14