Connecting Technology with Credentialing Verifications Donna Goestenkors, CPMSM, President June 15, 2016

Education Partners © 2016 All Rights Reserved 2

Objectives Apply knowledge and smart solutions to your credentialing practices. Push meaningful change. © 2016 All Rights Reserved 3

PREPARE YOURSELF © 2016 All Rights Reserved 4

MSP Core Competency Model PERSONAL Effectiveness CAREER Power SKILLS Efficiency © 2016 All Rights Reserved 5

MSP Core Competence CAREER Power PERSONAL Effectiveness SKILL Efficiency Core: ~Credentialing Management ~Privileging Management ~Practitioner Competence Mgmt. {privileging, FPPE, OPPE} ~Compliance Management ~Enrollment Management ~Onboarding Management ~Office Management ~Document Management ~Acquisition Management ~Technology Management ~Relationship Management ~Development Management © 2016 All Rights Reserved 6

Process Framework Definition of Credentialing Design a smart Credentialing System MSP core competencies in Credentialing Where is Credentialing performed Know the rules of Credentialing Credentialing benefits Audits validate a credentialing process and product integrity Top 25 Credentialing elements Web Credentialing verification sources © 2016 All Rights Reserved 7

Credentialing IS Examination and review of credentials of individuals meeting a set of educational or occupational criteria and therefore being licensed in their field. The process is conducted periodically because of the responsibility of the organization for any claims of malpractice by its staff. © 2016 All Rights Reserved 8

Credentialing Is NOT… Privileging Payor Enrollment © 2016 All Rights Reserved 9

Credentialing System The methodology or process of managing the credentialing project. © 2016 All Rights Reserved 10

MSP Competence Credentialing Management Theory Project Plan System Implement Monitor Audit/Measure Ongoing Improvement © 2016 All Rights Reserved 11

Where Is Credentialing Performed? Hospital System Academic Urban/Community Critical Access Specialty Cancer Behavioral Health Clinics, etc. © 2016 All Rights Reserved 12

Where? Credentials Verification Organization (CVO) Managed Care Organization (MCO) Ambulatory Facility (Surgery Center, Rehab, etc.) Physician Solo/Group Practice Remote Other © 2016 All Rights Reserved 13

Know The Rules Government Regulations & State Law (Federal & State) Centers for Medicare/Medicaid (CMS) State Law/Statues Vary © 2016 All Rights Reserved 14

Who Defines The Rules Healthcare Legislation National Practitioner Data Bank (NPDB) Office of Inspector General (OIG) Healthcare Case Law © 2016 All Rights Reserved 15

Who Defines The Rules Accreditation Body The Joint Commission (TJC) Healthcare Facilities Accreditation Program (HFAP) DNV GL National Committee for Quality Assurance (NCQA) Accreditation Association for Ambulatory Health Care (AAAHC) © 2016 All Rights Reserved 16

Who Defines The Rules Hospital CVO MCO Other Policies & Procedures Contracts © 2016 All Rights Reserved 17

Identify Your Rule Makers © 2016 All Rights Reserved 18

Well Designed Credentialing System Credentialing Process Credentialing Software (if applicable) Credentialing Application/Reapplication Credentialing Supplemental Forms Credentialing Checklist Red Flag investigation © 2016 All Rights Reserved 19

Well Designed Credentialing System Collection of Verifications methodologies Analysis Evaluation Action (Hospital, MCO) Notification of Action © 2016 All Rights Reserved 20

Benefits of Well Designed Credentialing Plan Understand the WHY Expand knowledge of theory Have critical conversations Administration Medical Staff MSP orientation/education Increase competence Valuable team member © 2016 All Rights Reserved 21

Benefits of Well Designed System Efficiency Continuity Automation Traceability Customer Service © 2016 All Rights Reserved 22

Benefits of An Efficient System Centralize Standardize Economize Reduce risk Adaptability © 2016 All Rights Reserved 23

Audits An objective examination and evaluation of records to ensure they are an accurate representation of the process or requirement. Internal or External/Independent © 2016 All Rights Reserved 24

Purpose Plan Search Discover Identify Risks Non-compliance Performance Verify Document Report Decision Making Action Process Improvement © 2016 All Rights Reserved 25

Value Of An Audit Validate compliance with requirements and processes Promotes standardization Reduce risk Ensures employees are performing their tasks correctly © 2016 All Rights Reserved 26

Value Of An Audit Identifies areas of improvement Targets informed decision making Validates department competence Validates MSP competence © 2016 All Rights Reserved 27

Credentialing Elements © 2016 All Rights Reserved 28

Verifications Application 2 - Education 3 - Post Graduate Training 4 - Board Certification 5 - Licensure © 2016 All Rights Reserved 29

Verification 1 Application © 2016 All Rights Reserved 30

Verification 2 Medical Education MDs, DOs, and PAs AMA Profile Service (American Medical Association) Subscription Fee DOs AOA Profile Service (American Osteopathic Association) Subscription Fee © 2016 All Rights Reserved 31

Verification 2 Medical Education Non-Physicians: National Student Clearinghouse Subscription Fee © 2016 All Rights Reserved 32

Verification 3 Post Graduate Training MDs and DOs AMA Profile Service (American Medical Association) Subscription Fee DOs AOA Profile Service (American Osteopathic Association) Subscription Fe e © 2016 All Rights Reserved 33

Verification 4 Board Certification MDs, DOs, Advanced Practice Practitioners Specialty Board website for certification status Example: American Board of Internal Medicine PSV Obtained At No Cost (usually) MDs, DOs CertiFACTS service of ABMS Subscription Fee © 2016 All Rights Reserved 34

Verification 4 Board Certification MDs, DOs, PAs AMA Profile Service (American Medical Association) Subscription Fee DOs AOA Profile Service (American Osteopathic Association) Subscription Fee © 2016 All Rights Reserved 35

Verification 5 Licensure State Li censing B oard W ebsite/PSV Example: Illinois Department of Financial and Professional Regulation: PSV o btained a t n o c ost (usually) Health Guide USA Online access health information sources hospitals and licensing boards © 2016 All Rights Reserved 36

Verification 5 Licensure AMA (American Medical Association) provides a link to access all state medical boards physician/medical-licensure/state-medical-boards.page physician/medical-licensure/state-medical-boards.page FSMB FCVS (Federation of State Medical Boards / Federation Credentials Verification Service) Subscription Fee © 2016 All Rights Reserved 37

Verifications Sanctions Against Licensure 7 - Professional Liability/ Malpractice Coverage 8 - Malpractice History 9 - Work History 10 - Current Clinical Competence © 2016 All Rights Reserved 38

Verification 6 Sanctions Against Licensure NPDB (National Practitioner Data Bank) State licensing boards are required to report to NPDB any sanction and other disciplinary action taken on against practitioner licensure Subscription Fee © 2016 All Rights Reserved 39

Verifications Medicare/Medicaid Sanctions 12 - Ongoing Monitoring of Sanctions & Disciplinary Actions 13 - DEA/State Controlled Substance 14 - Ability to Perform 15 - Medical Staff Membership © 2016 All Rights Reserved 40

Verification 12 Ongoing Monitoring of Sanctions & Disciplinary Actions OIG (Office of Inspector General) Website provides access to a downloadable LEIE (List of Excluded Individuals and Entities) May be possible to import the list to the credentialing system for auto-scanning purposes © 2016 All Rights Reserved 41

Verification 12 Ongoing Monitoring of Sanctions & Disciplinary Actions SAM (System for Award Management) Search for providers with sanctions State licensing boards often provide additional links to other information such as sanctions and other disciplinary actions Example: © 2016 All Rights Reserved 42

Verification 12 Ongoing Monitoring of Sanctions & Disciplinary Actions FSMB (Federation of State Medical Boards) FCVS (Federation Credentials Verification Service ) Subscription Fee © 2016 All Rights Reserved 43

Verification 12 Ongoing Monitoring of Sanctions & Disciplinary Actions NPDB (National Practitioner Data Bank) State licensing boards required to report to NPDB any sanctions and other disciplinary actions Subscription Fee © 2016 All Rights Reserved 44

Verification 13 DEA/State Controlled Substance Visual evidence of current certification NTIS (National Technical Information Service) database BEE B- D09DEE7BE1C0%7D/PageVars/Library/InfoManage/Guide.htm BEE B- D09DEE7BE1C0%7D/PageVars/Library/InfoManage/Guide.htm Subscription Fee Direct contact (phone call) to the DEA or the State CDS Agency © 2016 All Rights Reserved 45

Verification 15 Medical Staff Membership NAMSS PASS A service offered by NAMSS (National Association of Medical Staff Services) Subscription Fee Hospital Website Direct Link Example Brigham and Women’s Hospital in Boston PSV obtained at no cost (usually) © 2016 All Rights Reserved 46

Verification 15 Medical Staff Membership Health Guide USA Online access health information sources hospitals and licensing boards © 2016 All Rights Reserved 47

Verifications Clinical Privilege History 17 - National Practitioner Data Bank (NPDB) 18 - Criminal Background Check 19 - Identity 20 – Release & Authorization © 2016 All Rights Reserved 48

Verification 17 National Practitioner Data Bank (NPDB) Query Continuous Query Subscription Fee © 2016 All Rights Reserved 49

Verification 18 Criminal Background Checks Examples: HireRight Checkmate w.instantcheckmate.com w.instantcheckmate.com Subscription Fee © 2016 All Rights Reserved 50

Verification 19 Identity Personal View Government Issued ID Hospital ID Badge NTIS (National Technical Information Service) database B523-06F1204F7237%7D/PageVars/Library/InfoManage/Guide.htm B523-06F1204F7237%7D/PageVars/Library/InfoManage/Guide.htm Subscription Fee © 2016 All Rights Reserved 51

Verifications Peer References 22 - CME Documentation 23 - Case Log 24 - Notification Of Decision To Practitioner 25 - Onboarding © 2016 All Rights Reserved 52

© 2016 All Rights Reserved 53

POWER THOUGHT © 2016 All Rights Reserved 54

Speaker Contact Information Donna Goestenkors, CPMSM Team Med Global Consulting, LLC Telephone: (618) Website: Like Me: Connect with Me: Follow Me: © 2016 All Rights Reserved 55

RESOURCES Team Med Global Consulting Research & Development Credentialing Team: Gold Standard Credentialing Tool Subject Matter Expert & Field Experience Field Audit Tools Interviews & Surveys MSP Focus Groups & Healthcare Administrators Merriam-Webster Dictionary © 2016 All Rights Reserved 56

Dr. Mary Baker, CPMSM, CPCS Linda Van Winkle, CPMSM, CPCS Stephanie Russell, CPMSM, CPCS Lynne O’Connor, CPCS, CPMSM © 2016 All Rights Reserved 57 CREDITS

Matthew Stallard PowerPoint Design Consultant © 2016 All Rights Reserved 58 CREDITS

Credentialing Tool © 2016 All Rights Reserved 59

The MSP Career Guidebook Features Include: Frequently asked questions by MSPs Sample job descriptions, systematic assessment tools, planning techniques, and strategies for effective performance Real-life stories to illustrate specific points Purchase today or order your copy and receive a 10% courtesy discount: OR OR © 2016 All Rights Reserved 60

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