CPCS Study Guide / – Flashcards

The process of obtaining, verifying, and assessing the qualifications of a health care practitioner who seeks to provide patient care in or for a hospital

A process by which an organization reviews and evaluates qualifications of licensed independent practitioners to provider services to its members.

patient safety

1. Patient Safety 2. Risk Management concerns 3. Required by accrediting and regulatory agencies

Medicare Conditions of Participation - The CoPs are contained in the code of federal regulations are intended to protect patient health and safety and to ensure quality of care for hospitalized patients

Accreditation assists organizations in monitoring and improving quality of care. It can be used to meet certain Medicare certification requirements, organizations that are accredited are given "deemed status" meaning they meet the Medicare and Medicaid requirements for participation.

1. may favorably influence liability insurance premiums 2. may be required in order to obtain managed care contracts 3. Employers and unions may require accreditation for providing health care coverage to employees

1. The joint commission TJC 2. American Osteopathic Association Health Facilities Accreditation program (AOA-HFAP) 3.Det Norske Veritas Healthcare Inc. (DNV) 4. National Integrated accreditation for healthcare organizations (NIAHO) 5. National committee for quality assurance (NCQA) 6. URAC 7. Accreditation association for ambulatory health care (AAAHC)

Participate in the development, implementation, an ongoing assessment of bylaws, rules and regulations, policies & procedures to ensure continuous compliance with accreditation regulatory standards.

Medical Staff Organization - although various regulatory agencies & Accreditation bodies require certain organizational components, the formal structure and specific operational mechanisms are at the discretion of the MSO and governing body of the healthcare organization

Providing patient care, evaluation the quality of patient care, maintenance of the MSO.

It is a self governing entity which exists as an extension of the healthcare facility

the organizational structure of the medical staff as delineated in it's bylaws defined the framework within which medical staff appointees act and interact in hospital related activities.

Bylaws are written to conform to generally accepted guidelines for broad content categories - they ensure compliance with legal requirements and accreditation and regulatory agencies.

bylaws are reviewed and appropriate amendments are essential to keep up with changes in accreditation standards and regulatory requirements

Typically MSO's make provisiton for at least a biennial review of the bylaws.

the purpose of the bylaws committee is to review the bylaws and to make recommendations to the medical staff's executive committee (MEC)

bylaw changes are adopted by majority vote of the medical staff. Bylaw changes are not effective until approved by the governing boy.

Bylaws should include all items necessary to provide a basic frame work for the MSO and to fulfill requirements of the law, regulatory agencies, and accreditation bodies. Also some states have specific requirements for elements to be included in bylaws.

Detail what medical staff appointees may or may not do. such as requirements for specific clinical processes, rules of each clinical department, requirements for ER coverage, guidelines for obtaining consultation, membership dues, provisions for leave of absence, medical records completion, community call coverage requirements, meeting attendance, and other staff responsibilities and prerogatives.

the medical staff may delegate the authority for changing the rules and regulations to the MEC.

describe the course of conduct or action pursued or the management of a matter in certain circumstances. Policies are often used to address internal matters and may be subject to frequent change. The medical Staff may delegate the authority for changing the rules and regs to the MEC.

It is a good idea to audit bylaws, rules, regs, and policies to make sure that they comply with state regs and accreditation standards.

You should determine the basis for the bylaw requirement, if it is not required by accreditation standards, state of federal regs, confer with your legal counsel as to whether not to change the bylaws to reflect your current practice.

MCO's use policies and procedures to delineate required functions.

Hospitals governing body and medical staff define medical staff membership criteria in the bylaws.

Licensed independent practitioner are defined as any individual permitted by law and by the hospital to provide patient care services without direction or supervision within the scope pf his or her license, and in accordance with individually granted clinical privileges. Stat regs may define which practitioners are eligible for medical staff appointment.

The process by which the managed care organization authorizes contracts with or employs clinicians who are licensed to practice independently to provide services to it members.

They apply to all licensed practitioners or groups of practitioners who provide care to the organizations members

1.anyone who practices exclusively within an inpatient setting. 2.Those who practice exclusively within free=standing facilities and who provider care for organization members only as a result of members being directed to the facility 3. Dentists providing primary dental care only under a dental plan or rider 4. Pharmacists working for a pharmacy benefits management (PBM) organization to which the organization delegates utilization management functions 5. Covering practitioners (locum tenens) unless working for longer then 90 days and 6. Practitioners who do not provide care for members in a treatment setting (e.g. Board certified consultants)

Credentialing and privileging determine applicants eligibility for membership/participation to ensure compliance with accreditation and regulatory standards

the basic or "core" criteria are usually reflective of education, training, current competence, health status, and licensure. These criteria should be outlined in bylaws, policies, and or rules and regs.

requirements set by forces outside the organization, including accrediting and certifying bodies such as TJC, NCQA, and state and federal regs such as CoPs. State laws may also describe which providers can be members of the medical staff.

those factors defined by the hospitals medical staff and governing board, or the MCO's board. This criteria may include board certification, office within a certain distance from the institution, alternate coverage, need for particular specialty, application fee, minimum amounts for professional liability insurance, ect.

medical doctors, doctors of osteopathy, dentists, podiatrists, psychologists, advanced practice nurses ect. Then it is up to the hospital / medical staff as to whether these practitioners will be allowed to practice independently within the institution and if so whether they are eligible for medical staff membership / appointment / and or privileges.

Your bylaws must describe the qualifications required of a candidate in order for the medical staff to recommend appointment by the governing body.

They must include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges.

applicant's character, competence, training, experience, and judgement

They are responsible to determine whether to grant, deny, continue, revise, discontinue, limit, or revoke specified privileges, including medical staff membership after considering the recommendation of the medical staff. In all instances the governing body's determination must be consistent with the established hospital medical staff criteria, as well as state and federal laws and regulations. Only the governing body has the authority to grant a practitioner privileges to provide care in the hospital

they require the hospital, based on recommendations by the organized medical staff and approval by the governing body to develop criteria to be used in making decisions to grant, limit or deny a requested privilege. Medical staff membership and professional privileges can not be dependent upon certification, fellowship, or membership in a specialty body or society.

Current valid license current valid unrestricted DEA or state controlled substance license. Relevant education, training, and experience Board qualified/board certified for physicians minimum of 5 years of work history current liability insurance in limits set by plan admitting privileges in good standing at the applicant's admitting facility maintain office site and medical records in accordance with requirements agree to abide by credentials, QI, and UM procedures as applicable agree to abide by participation contract

Types of practitioners credentialed and recredentialed Verification sources used credentialing and recredentialing criteria process used to make credentialing and recred decisions process for managing the credentialing files that meet the criteria process for delegating credentialing or recred process for ensuring nondiscrimination in credentialing or recred Process for notifying practitioners if information obtained during the organizations credentialing process varies substantially from the informatino they provide to the organization. Process for ensuring the practitioners are notified of the initial credentialing decision and recred denial decision within 60 calendar days of the committees decision (it is not necessary to notify regarding a recred approval) Medical director or other designated physicians direct responsibility and participation in the credentialing program process for ensuring the confidentiality of all information obtained in the credentialing process, except as otherwise provided by law. Process for ensuring that listings in practitioner directories and other materials for members are consistent with credentialing data including education, training, certifications and specialty and Standard and thresholds for office site visit criteria and medical treatment record keeping practices.