Credentialing: 2017 Updates and Frequently Asked Questions Veronica C. Locke 4/27/2017

Overview of credentialing standards, including updates Distinct differences between CR standards and certification programs (CR and CVO certification) Discussion

NCQA’s Credentialing Standards Section 1: NCQA’s Credentialing Standards

Total versus Partial Credentialing Which NCQA programs have credentialing? Total comprehensive credentialing programs Accreditation Health Plan (HP) Accreditation Managed Behavioral Health Organizations (MBHO) Accreditation Certification Credentialing (CR) Certification Credentialing Verification Organizations (CVO) Certification Partial Credentialing Programs Accreditation/Certification Disease Management (DM) Accreditation/Certification Case Management (CM) Accreditation CM-Long Term Services and Support (LTSS) Distinction

Breakdown of Credentialing Programs Similarities and differences…   HP MBHO UM-CR CVO DM CM Credentials Verification Y  Y Ongoing Monitoring Credentialing Policies Somewhat CR Delegation, including Agreement/Collaboration with Clients Internal Quality Improvement Process Credentialing Committee Recredentialing Cycle Length Practitioner Office Site Quality Notification to Authorities and Practitioner Appeal Rights Protecting Credentialing Information Assessment of Organizational Providers Somewhat 

Credentialing Standards Fundamentals

Just as a reminder… Terminology Practitioner = person Provider = facility

So, why is credentialing really important?

Common Denominator: The organization has a rigorous evaluation process that allows it to make knowledgeable decisions about potential practitioners in the network

Practitioner Credentialing Guidelines Written policies and procedures include: Types of practitioners credentialed/ recredentialed Verification sources used CR criteria Making CR decisions CR file management process that meets the organization’s criteria CR delegation Ensure that the CR process does not discriminate Notify practitioners of variances in information Ensure that practitioners are notified of the CR decision within 60 calendar days Medical director or designated physician’s role Ensure confidentiality of information Directories and other materials are consistent with collected CR data

Scope of Credentialing Evaluating policies and real files The scope of file review is more prescriptive and specified in the Standards and Guidelines. Practice independently Independent relationship Service within the medical benefit NCQA evaluates both policies and credentialing files

Independent Relationships NCQA’s credentialing “Golden Phrase” Directing a member to a specific practitioner (not provider) or practitioner group Not directing a member to a provider or facility (i.e., hospital)

“within the scope of credentialing” Do you have real-life examples of practitioners who are “within the scope of credentialing”

Who is “within the scope of credentialing”? Practitioner Type Scope of credentialing? Primary care physicians Pathologists Independently practicing NPs Podiatrists Radiologists Anesthesiologists Mammography center physicians PhD Psychologists ER physicians Yes No Yes Yes Depends Depends No Yes No

Practitioner Rights Written policies and procedures include: Practitioner’s right to review information submitted to support the CR application Practitioner’s right to correct erroneous information Practitioner’s right to be informed of status of application, upon request

Credentialing Committee The credentialing committee: Includes participating practitioners Reviews practitioners who do not meet established thresholds Does not need to review clean files Final review committee by NCQA’s standards

Credentialing Committee Things to remember: NCQA does not specify committee size or number of participating specialties Regional or national committees are acceptable Must have representation from practitioners within scope of credentialing Credentialing policies must specify who reviews “clean” files

Credentialing Decisions Two methods: One-step process: All files go to credentialing committee Two-step process: Clean files go to medical director (or other qualified physician) for review and approval Files that do not meet established criteria go through the credentialing committee for review

Credentialing Decisions Determining the credentialing date for practitioners is based on committee decision date. For clean files: Medical director approval date For files that go to committee: Date of committee meeting when decision was made NCQA does not prescribe the decision that the organization makes, only that it: Collects and verifies information, and Makes a decision within a specified period Determining credentialing date for practitioners is based on committee decision date NCQA does not prescribe the decision that the organization makes

Credentialing Verification/ Recredentialing Cycle Length What is evaluated? Determining the credentialing date for practitioners is based on committee decision date. For clean files: Medical director approval date For files that go to committee: Date of committee meeting when decision was made NCQA does not prescribe the decision that the organization makes, only that it: Collects and verifies information, and Makes a decision within a specified period Verification sources Timeliness of verification Decision process Timing of recredentialing, if applicable

Primary source verification What is appropriate? PSV: Process for verifying credentialing information comes directly from the entity that originally issues the practitioners’ credentials. Example: State licensing board that issues practitioners’ licenses. NCQA also allows verification from accepted sources that are specified in the credentialing standards. Directly from issuing entity NCQA-approved source Specified source in organization’s credentialing policies

What needs to be verified? Credentials requiring verification Licensure DEA/CDS certificates Education/training Board certification, if applicable Work history Malpractice history

Obtaining information How to get the information Oral Written Internet Websites Cumulative reports Automated systems Agents of approved sources Issues credentials on behalf of primary source with written acknowledgement/confirmation that entity is able to distribute

Information Verification Source Current, valid license (for all states where practitioner is providing care for the organization) State licensing agency DEA/CDS (for all states where practitioner is providing care for the organization) Copy of certificate Visual inspection of certificate DEA/CDS Agency confirmation NTIS database entry AMA Masterfile State pharmaceutical licensing agency Work history Application Curriculum vita Malpractice claims history NPDB query or initial report from NCQA-recognized disclosure service Five years claims history from malpractice carrier

Information Verification Source Education/training (MD/DO) as board certification as highest level ABMS entry AMA Masterfile AOA Profile Report or Physician Masterfile Confirmation from specialty board Confirmation from state licensing agency (proof of PSV needed) Education/training (MD/DO) as residency as highest level Confirmation from residency program Education/training (MD/DO) as education as highest level Confirmation from medical school ECFMG (intl graduates after 1986) Education/training (non-MD/DO) as education as highest level Confirmation from professional school Confirmation from specialty board or registry (proof of PSV needed)

Obtaining information (cont.) Time frames The organization verifies the license on 7/1/2014. The file is presented to the committee on 1/2/2015. NCQA counts backward from 1/2/2015 (the Credentialing Committee decision date) to determine if the limit is met. Licensure: Up to 180 calendar days Malpractice history: Up to 180 calendar days Work history: 365 calendar days Education/training: No limit Board certification: Up to 180 calendar days DEA: No limit

Do you have real-life examples of meeting timeliness requirements?

Example of timeliness Licensure: 180 calendar days Organization verifies a practitioner’s license in the state of which she provides medical care: 7/1/2015 Practitioner’s file is presented to the organization’s Credentialing Committee: 1/2/2016 NCQA counts backward from 1/2/2016 (the CC date) to determine if timeliness requirement was met Did the organization meet NCQA’s timeliness requirements? The timeliness requirement is NOT MET because the information is 185 calendar days old

Sanction information Appropriate sources The organization verifies the license on 7/1/2014. The file is presented to the committee on 1/2/2015. NCQA counts backward from 1/2/2015 (the Credentialing Committee decision date) to determine if the limit is met. State sanctions, restrictions on license or limitations Medicare/Medicaid sanctions Acceptable sources: State agencies, NPDB, FSMB (licensure) FEHBP, OIG, FSMB, NPDB, Medicare/Medicaid sanctions report (Medicare/Medicaid)

Credentialing Application Required attestation questions NCQA does not prescribe the answer on the application, just that the organization has the practitioner attest to the questions Reasons for inability to perform Lack of present illegal drug use History of loss of privileges or any disciplinary actions History of loss of licensure and felony convictions Current malpractice coverage Attestation that everything is correct and complete

Recredentialing Cycle Length How long is enough? Within 36-month time frame Count to the month, not day

Recredentialing Cycle Length Termination and reinstatement Administrative terminations do not “stop the clock” on timeliness Organization is unable to recredential a practitioner within 36 months of initial credentialing Receipt of credentialing information within 30 calendar days (before 37th month) Avoids initial credentialing (reverifying all credentials in CR 3) Scores down on timeliness requirement Receipt of credentialing after 30 calendar days (after 37th month) Needs to initial credential practitioner

CR 4: Recredentialing Cycle Length Extending the recredentialing cycle length Active military assignment Maternity (or medical) leave Sabbatical The organization documents the reason for the extension and recredentials practitioners within 60 calendar days of return.

Ongoing Monitoring/Interventions The organization collects and reviews: Sanction alert services acceptable Medicare/Medicaid sanctions Limitations/sanctions on licensure Member complaints Adverse events Interventions for instances of poor quality Demonstration of a systematic monitoring process for evaluating quality, safety issues between credentialing cycles

Actions against Practitioners The organization has a process for: Range of actions available Reporting to authorities Appeal process Has the organization made the process known to practitioners? Is this process communicated in writing for the practitioners, including specific reasons for the decision?

Organizational Provider Assessment For HPs and MBHOs only Organizations policies specify that before it contracts with a provider and every three years thereafter, it: Confirms provider is in good standing with state and federal regulatory bodies, and Confirms that the provider has been reviewed and approved by an accredited body, or Conducts an onsite assessment if the provider in not accredited

Organizational Provider Assessment (cont.) For HPs and MBHOs only NCQA does not prescribe accrediting bodies to use Organizations outline the accrediting bodies it uses Examples of accrediting bodies: The Joint Commission (TJC) Commission on Accreditation of Rehabilitation Facilities (CARF) Accreditation Association for Ambulatory Health Care (AAAHC)

Organizational Provider Assessment (cont.) For HPs and MBHOs only Medical Behavioral health Hospitals Home health agencies Skilled nursing facilities Freestanding surgical centers Inpatient Residential Ambulatory

In summary… Ensure that CR policies are complete and an effective credentialing committee is in place. Confirm that CR criteria and verification sources meet NCQA requirements. Ensure timely verification and decision-making. Implement a process for ongoing monitoring. Institute a well-defined practitioner appeal process.

Authority ≠ Responsibility Delegation What is delegation? An organization (client) gives authority to another organization (delegate) to perform an activity that the client would otherwise perform to meet NCQA’s requirements Client organization retains responsibility (accountability) Authority ≠ Responsibility

Delegation (cont.) Two Aspects Delegation Giving another entity authority to perform activities Delegation Oversight Making sure entity performs to organization’s and NCQA’s standards

Delegation What is delegation? Delegation Oversight requirements Written delegation agreement Provisions for PHI Pre-delegation evaluation Annual review of policies and procedures, including file audit, as appropriate Semiannual reporting Opportunities for improvement

Delegate organization Subdelegation Example I love this slide. Can we make font bigger. Also, maybe animate? you can make this a build with the arrows and boxes. happy to help if you want I will add animation. Client organization Health plan delegates credentialing of behavioral healthcare practitioners Delegate organization MBHO delegates verifications Subdelegate CVO performs verifications

Differences and similarities of credentialing standards Section 2: Differences and similarities of credentialing standards

Similarities between CR and CVO Four similarities Quality improvement process Privacy requirements Written credentialing policies Delegation cooperation Quality improvement process Privacy requirements Written credentialing policies Delegation cooperation (and evidence)

Differences between CR and CVO Two distinct differences Time frames Credentialing Committee