CPCS Study Guide /

Joint commission define credentialing as
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

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

The number one reason for credentialing is
patient safety

The three main reasons for credentialing are
1. Patient Safety
2. Risk Management concerns
3. Required by accrediting and regulatory agencies

What does CoPs stand for
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

Why get Accredited
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.

Other reasons to become accredited
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

After CMS approves an Accreditor they are given deemed status, name the accreditors that have deemed status
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)

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

What is the MSO
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

What are the functions of the MSO
Providing patient care, evaluation the quality of patient care, maintenance of the MSO.

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

How is the medical Staff structured
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 – why are they written
Bylaws are written to conform to generally accepted guidelines for broad content categories – they ensure compliance with legal requirements and accreditation and regulatory agencies.

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

How often should your bylaws be reviewed
Typically MSO’s make provisiton for at least a biennial review of the bylaws.

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

When do bylaw changes go into effect
bylaw changes are adopted by majority vote of the medical staff. Bylaw changes are not effective until approved by the governing boy.

What should be included in your bylaws
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.

Rules and Regulations –
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.

How can changes be made for rules and regulations for individual departments
the medical staff may delegate the authority for changing the rules and regulations to the MEC.

Policies and Procedures –
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.

Why should MSP’s be familiar with the regs and accreditation standards that apply to their organization?
It is a good idea to audit bylaws, rules, regs, and policies to make sure that they comply with state regs and accreditation standards.

What if you find out you are not compliant with your bylaws?
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.

Instead of Bylaws what do MCO’s use?
MCO’s use policies and procedures to delineate required functions.

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

What is an LIP
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.

NCQA describes credentialing as-
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.

Who do the credentialing standards apply to?
They apply to all licensed practitioners or groups of practitioners who provide care to the organizations members

Practitioners who do not need credentialed are
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)

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

Name some of the criteria for appointment to a medical staff or provider panel.
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.

External Criteria for membership are
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.

Internal Criteria for membership are
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.

Depending on the individual state law independent practitioners can include
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.

Medicare CoPs requirements regarding Medical Staff Membership
Your bylaws must describe the qualifications required of a candidate in order for the medical staff to recommend appointment by the governing body.

What criteria must the bylaws include to meet CoPs requirements
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.

CoPs require a mechanism be established to examine credentials of prospective member what is the minimum criteria for appointment
applicant’s character, competence, training, experience, and judgement

The governing body is responsible for what part of staff membership
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

TJC bylaws requirements regarding medical staff membership
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.

MCO’s policies and procedures define which prividers are allowed to participate on the provider panel and the criteria used to reach a credentialing decision are
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

NCQA requirement regarding credentailing criteria are that the MCO’s policies and procedures must include
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.

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