Credentialing Standards Presenters: Mei Ling Christopher Veronica Harris Royal Agenda Introductions Definitions vs. 2016 Regulatory Updates Survey Process Reminders Questions and Answers 222 Introduction Biographies Mei Ling Christopher Veronica Harris-Royal Participant s Assessment 333 1
Definitions Audit: A health plan must conduct an audit at least every 12 months; 2-month grace period allowed (14 months). Corrective Action Plan (CAP): In a CAP, the organization addresses each identified deficiency with a detailed account of the steps it will take to correct the deficiency and the time frame for completion. Delegation: A formal process by which the organization gives another entity the authority to perform certain functions on its behalf. 444 Definitions cont d Documented Process: Policies and procedures, process flow charts, protocols, and other mechanisms that describe the methodology used by the organization to complete a task. Element: The scored component of a standard that provides details about performance expectations. Each element is evaluated to determine the degree to which an organization meets the standard s requirements. 55 5 Definitions cont d Factor: A scored item in an element. Example: An element may require an organization to demonstrate that its policies and procedures include four specific items; each item is a factor. Policies and Procedures: A documented process that describes the course of actions taken and the method in which the action will be carried out by the organization s staff to achieve objectives. Sub-delegation: The organization s delegate gives a third entity the authority to carry out a delegated function. 666 2
Acronyms California Department of Insurance (CDI) Centers for Medicare & Medicaid Services (CMS) Department of Health Care Services (DHCS) Medi-Cal Department of Managed Health Care (DMHC) National Committee for Quality Assurance (NCQA) 777 Regulatory Updates NCQA See attachment CMS Medicare is no longer deemed to NCQA DMHC SB 137 Provider Directories 88 Survey Process Audit Tool Updates Desk Audit Process Delegation to vendor-type Entity Delegation Oversight Ongoing Monitoring Organizational Providers MOC Process 99 3
Training Tool Updates Changed all references from HDOs to Organizational Providers Removed all references to HIPDB Minor wording changes from NCQA Removed all outdated references 10 Training Tool Updates CR 1.A.2 Verification Sources The policy must describe the sources used to verify credentialing information. CR 1.B.2 Practitioner Rights The requirement changed from the person to whom corrections must be submitted to where they must be submitted. 11 Training Tool Updates CR 3.A.3 Board Certification Board Certification Applies to Nurse Practitioner/Physician Assistants CR 3.B.4 Medi-Cal Suspended and Ineligible Review Medi-Cal Suspended and Ineligible Report is required at initial and recredentialing 12 4
Training Tool Updates CR 6.C Medi-Cal Suspended and Ineligible Report Must review the list on a monthly basis CR 6 A.4 Ongoing Monitoring of Adverse Events Limited to PCPs and high-volume BH providers CR 6.B Medicare Opt-Out Report Applies to: MD, DO, DDS, DMD, DPM, OD and PA, NP, CNS, CRNA, CNM, Psychologist, CSW, RD or Nutrition Professional 13 Training Tool Updates CR 8.A.1 Assessment of Organizational Providers Confirms the provider is in good standing with state and federal regulatory bodies Policies must specify the sources used. NCQA Certified Provider Organizations Removed references throughout CR 8 because POs are not certified for Organizational Providers. 1414 Training Tool Updates CR 9 Delegation A.3 How and to whom information is reported A.4 and 5 reversed Element D added more examples of how to conduct a pre-delegation evaluation and noted it cannot be older than 12 months. Performance records (e.g., Audit) Exchange of documents and review Pre-delegation/Committee meetings Telephone consultation Virtual review 15 5
Desk Audit Process SharePoint Site, WebEx, Go To Meeting File Transfer Protocol (FTP) a secure means of transferring computer files Either the Health Plan or the Delegate may have the ability You must sign in to access the data You can limit the amount of time the files are available Allows for large files to be reviewed without having to email Examples: sharefile.com, firezilla, dropbox 16 Delegation to vendor type Entity If you use another company/entity to obtain credentialing information it is delegation, even if it is just for sanctions monitoring. If you log into their web-based system to pull your queries, it is delegation. Delegation/CR 9 is applicable and must be assessed. 17 Delegation to vendor type Entity CR 9 A: Delegation Agreement 1. There must be an agreement/contract. 2. It must describe the activities being delegated. 3. It must require at least semiannual reporting. 4. Describe the remedies available if they don t fulfill their obligations. 5. Process to evaluate the performance. 18 6
Delegation to vendor type Entity CR 9 C: Right to Approve and Terminate - N/A You are not delegating decision making. CR 9 D: Pre-delegation Evaluation This might include a review of their website, contract or teleconference. 19 Delegation to vendor type Entity CR 9 E: Review of Credentialing Process 1. Audit of files N/A. 2. ly evaluation of performance. Were there any issues with their reports, their systems, etc. 3. Semi-annually evaluate regular reports. If you received or pulled reports more than semiannually, then they met this requirement. CR 9 F: Opportunities for Improvement If none were identified then this is N/A, otherwise they should have addressed the opportunities. 20 Delegation Oversight Changed Delegation oversight process for delegates with more than four Sub-Delegates to align with NCQAs process of oversight: Auditors will select and review a sample of up to 4 Sub-Delegates for oversight of CR 9, Elements A,C-F. Each audit year a selection of different sub-delegates will be reviewed. 21 7
Ongoing Monitoring CR 7: Element A - Ongoing Monitoring and Interventions Implementing ongoing monitoring and makes appropriate interventions by: 1. Collecting and reviewing Medicare and Medicaid sanctions. 2. Collecting and reviewing sanctions or limitations on licensure. Review needs to be conducted within 30 calendar days of release by the reporting entity. 22 Ongoing Monitoring If the reporting entity does not publish sanction information on a set schedule, the organization: Document that the reporting entity does not release information on a set schedule. Queries for this information at least every six months. If the reporting entity does not release sanction information reports, the organization Conducts individual queries every 12-18 months on credentialed practitioners. 232 3 Ongoing Monitoring Cont d Additional Methods of Review Use of Sanction Alert Services. Show evidence of subscription Review within 30 calendar days of a new alert/new release Use of Continuous Query Use of CVO Surveillance Reports 24 8
Ongoing Monitoring Cont d 2525 Ongoing Monitoring Cont. 3. Collecting and reviewing complaints. Investigating practitioner member complaints upon receipt and evaluating the practitioners history of complaints. Evaluating the history of all practitioner complaints, at least every 6 months. 26 26 Ongoing Monitoring 4. Collecting and reviewing information from identified adverse events. Monitoring at least every 6 months. 5. Implementing appropriate interventions when it identifies instances of poor quality related to Medicare/Medicaid, License, Complaints and Adverse Events. 27 9
Organizational Providers CR 8: Assessment of Organizational Providers. Evaluating the quality of contracted providers/facilities Review and Approval of Providers/Facilities. Policies for assessing prior to contracting and at least every 36 months/3 years thereafter. Confirms that the provider is in good standing with state and federal regulatory bodies. State Agencies (License Verification) Federal Agency (OIG Query) 28 Organizational Providers Confirms that the provider has been reviewed and approved by an accrediting body. Applicable accrediting body. (e.g. The Joint Commission(TJC), Det Norske Viertas(DNV), Accreditation Association for Ambulatory Healthcare(AAHC)) 29 Organizational Providers Conducts an onsite quality assessment if the provider is not accredited. Policy and procedures include assessment criteria for each type of provider and ensures that the provider/facility credentials their practitioner. 30 10
Organizational Providers CMS or state review (must be conducted within 36 months of review/approval) Survey Report Letter from CMS or state, stating that the facility was reviewed and passes inspection Report meets the organizations quality assessment criteria or standards. 31 31 Organizational Providers Medical Providers (Also CMS Providers) Hospitals Home Health Agencies, Skilled Nursing Facilities, Free Standing Surgical Centers Behavioral Healthcare Providers Inpatient Residential Ambulatory 32 Organizational Providers Additional CMS Providers and Suppliers Clinical laboratories Comprehensive outpatient rehabilitation facilities (CORF) End-stage renal disease services providers Federally qualified health centers (FQHC) Hospices Outpatient diabetes self-management training providers Outpatient physical therapy providers Portable X-ray suppliers Rural health clinics (RHC) Speech pathology providers 33 11
Organizational Providers 34 Organizational Providers 35 MOC Process The American Board of Medical Specialties (ABMS) no longer provides expiration dates after the practitioner s certification expires for the following boards listed below. The boards will utilize an annual re-verification date to document current certification: American Board of Internal Medicine April 1 st of each year American Board of Family Practice February 15 th of each year American Board of Pediatrics February 15 th of each year American Board Psychiatry and Neurology March 1 st of each year American Board of Radiology March 15 th of each year 36 12
Reminders When changing MSOs the PO should take the following with them: Ongoing Monitoring reports for their practitioners Credentialing Committee Minutes Credentialing Files you can continue with the recredentialing process if you have them, if not you must initially credential all providers Organizational Provider files and spreadsheets HIV/AIDS Screening documents and Memos Office Site Visit reports 37 Reminders Valid DEA - Practitioners must have a CA DEA at the time of approval or documentation of a practitioner who will prescribe until the CA DEA is received. Hospital Privileges Document of coverage if the practitioner does have clinical privileges. Recredentialing Reviewing and documenting noncompliance for timeliness. Site Visit Tools Review during each annual audit. Work History Evidence of signature/initial and date of review. 38 Reminders CPPA California Participating Practitioner Application may be found on the ICE website: http://www.iceforhealth.com/library.asp?sf=&scid=276 4#scid2764 FAQs http://www.iceforhealth.com/viewfaqsall.asp Review previously submitted questions/answers Submit your own questions for review Review questions from the July Training session 39 13
Questions & Answers Thank you in advance for completing our evaluation/survey at the close of the session. 40 14