CERTIFICATION FOCUSED STUDY PROGRAM EDGE-U-CATE, LLC CERTIFICATION FOCUSED STUDY PROGRAM for CPCS 2017 Section 1 Developed by Janet Wilson, CPMSM, CPCS ©Edge-U-Cate, LLC This documentation is proprietary and cannot be used or  duplicated without the express permission of Edge-U-Cate, LLC

WHY CREDENTIAL? HOSPITALS/SURGERY CENTERS = Assure that only qualified practitioners are granted membership and privileges MANAGED CARE = Assure that only qualified practitioners are approved to provide services to members

Review of Accreditation and Regulatory Entities The Joint Commission (TJC) accredits subscriber hospitals, ambulatory care centers, surgery, rehab centers, long term care centers, etc. Healthcare Facilities Accreditation Program (HFAP) provides accreditation programs for allopathic and osteopathic acute care hospitals, critical access hospitals, ambulatory surgical centers, ambulatory care/office based surgery, clinical laboratories, and behavioral health facilities. While previously primarily osteopathic focused, HFAP is now authorized by the Centers for Medicare and Medicaid Services (CMS) to survey all hospitals for compliance with the Medicare Conditions of Participation and Coverage.   The Centers for Medicare & Medicaid Services (CMS) is a branch of the U.S. Department of Health and Human Services. CMS is the federal agency that administers the Medicare program and monitors the Medicaid programs in each state.

Review of Accreditation and Regulatory Entities The National Committee for Quality Assurance (NCQA) manages voluntary accreditation programs for individual physicians, health plans, medical groups. NCQA also manages certification programs for CVO’s. URAC, formerly known as the Utilization Review Accreditation Commission promotes healthcare quality by accrediting healthcare organizations including medical management organizations (disease management, case management, health call centers, Independent Review Organizations, etc.), health plans (HMOs, PPOs, etc.), hospitals and health websites

Review of Accreditation and Regulatory Entities The Accreditation Association for Ambulatory Health Care (AAAHC), accredits ambulatory health care organizations, including ambulatory surgery centers, office-based surgery centers, endoscopy centers, and college student health centers, as well as managed care organizations, such as health maintenance organizations and preferred provider organizations.

REVIEW OF CREDENTIALING STANDARDS/ REQUIREMENTS

State Mandated Applications Addendums Pre-Application State Mandated Applications Addendums CAQH (Council for Affordable Quality Healthcare) Don’t Modify Applications – legal document

Complete Application Best Practice Don’t start verification process until all information complete and attachments received Reality Use best judgment based on documents received and required turn around times Follow bylaws/policies

Verification Process (I) = Initial Application Process (R) = Reappointment/ Reappraisal Process

Practitioners Credentialed- TJC Licensed Independent Practitioner (LIP) = Any LIP permitted by law and organization to provide care, treatment, and services without direction or supervision within the scope of the individual’s license and consistent with individually granted privileges. Traditionally MD, DO, DMD, DDS, DPM

APN or PA - TJC If APN or PA function as LIP, they must be credentialed through organized medical staff If non-LIP APN or PA, may be credentialed through medical staff standards or human resources equivalent process. Equivalent process must be approved by governing body and must include communication and input from MEC

APN or PA - TJC Equivalent process must include: - a documented evaluation of the applicants credentials - a documented evaluation of the applicants current competence - documented peer recommendations - process must include input from individuals and committees,including the medical executive committee, on order to make an informed decision regarding request for privileges

Practitioners Credentialed – NCQA P&P’s that apply to all licensed practitioners who provide care to the organization’s members All LIP’s certified or registered by the state to practice independently Must be credentialed - Physicians (MD/DO), Oral Surgeon/Dentists, Podiatrists, Chiropractors, non- physician practitioners with independent relationship with organization. Further defined as when organization selects and direct members to individual or group (ie. practitioners members can select as PCP)

Practitioners Credentialed – NCQA Must credential behavioral health specialists who are licensed, certified or registered by state and practice independently including Psychiatrists, Addiction Medicine Specialists, MSN, MSW who practice independently Do not have to credential: Practitioners contracted to practice exclusively in inpatient setting (Pathologists,Radiologists,Anesthesiologists, Hospitalists, Telemedicine, Neonatologists, ED phy) Dentists who provide primary dental care Locum Tenens

Practitioners Credentialed - CMS Governing body determines, in accordance with state law, which categories of practitioners are eligible for appointment to the medical staff At a minimum, medical staff must be composed of physicians (MD/DO) Other practitioners may be included as defined by Social Security Act (DDS/DMD, OD, DC) Others as defined by governing body (ie. NP, PA, CRNA, Midwives)

Practitioners Credentialed - CMS Non-physicians performing surgical tasks (dentists, podiatrists, RN first assistant, NP, surgical techs) Requires definition of surgical procedures that must be supervised and degree of supervision (ie. present in OR, in line of sight) Practitioners may be granted privileges without membership

Practitioners Credentialed - HFAP Governing body determines, in accordance with state law, which categories of practitioners are eligible for appointment to the medical staff At a minimum, medical staff must be composed of physicians (MD/DO) Other practitioner disciplines as defined by governing body Medical staff membership limited to licensed physicians, DDS, DPM

Practitioners Credentialed - HFAP Allied health practitioners (AHP) may be granted privileges Governing body, following consultation with medical staff, determines AHP disciplines All practitioners that provide medical/surgical care either directly or under supervision must be credentialed

Practitioners Credentialed - URAC Credentialing Program Plan defines participating providers and facilities who must be credentialed. At a minimum: Participating providers who are contracted to provide health care services to consumers Facilities that provide covered health care services to consumers Practitioners/facilities listed in directory

Practitioners Credentialed - AAAHC As approved by the Board, Bylaws or P&P, establish minimum training, experience, and other requirements for physicians and other healthcare practitioners. At a minimum, physicians and dentists.

Primary Source Verification The original source that can verify the accuracy of a credential, qualification, or other information reported by the practitioner Required by all accrediting bodies

Designated Equivalent Source (DES) - TJC Primary source may designate another organization as its agent Entities that have been determined to maintain specific credentials information identical to information at primary source AMA, AOA, ECFMG, etc.

Secondary Source – TJC First must attempt to verify primary source If entity closed or records not available.. - may contact another hospital to verify information - may contact practitioner who served at hospital at same time

Medical Education TJC Requirement (I) primary source verification from Medical School Accepted designated equivalent sources: AMA Profile (US and Puerto Rico), AOA Profile, ECFMG NCQA Requirement (I) Primary source verification from Medical School Not required if board certified or if residency has been verified Alternate sources: Medical School, AMA/AOA profile,ECFMG (after 1986), state licensing agency If state licensing agency is utilized, documentation must be updated annually

Medical Education CMS Requirement Medical staff must have a mechanism to examine evidence of professional education Must be included in criteria for membership/privileges CMS does not specify acceptable sources for verification HFAP Requirement Primary source verification required Additional source: AMA Profile, AOA Profile, ECFMG

Medical Education URAC Requirement Credentialing application includes history of education PSV not required if board certified May use state licensing board if documented AAAHC Requirement PSV required at initial appointment

Post Graduate Training TJC Requirement (I) Primary source verification from training programs Accepted Designated Equivalent Sources for U.S. and Puerto Rico: AMA Profile, AOA Profile NCQA Requirement (I) Primary source verification from residency training program Alternate sources: AMA Profile, AOA Profile, state licensing agency Not required if board certified

Post Graduate Training CMS Requirement Medical Staff must have a mechanism to verify training and experience Governing Body ensures criteria for selection is based on : (1)character (2)competence, (3)training (4)experience (5)judgment HFAP Requirement Training must be sufficient to support requested privileges PSV required through training program, AMA Profile, or AOA Profile

Post Graduate Training URAC Requirement If not board certified must verify highest level of education. Must document history of education/training on application Time limit: six months AAAHC Requirement Primary source verification required at initial appointment

Board Certification TJC Requirement Not required unless bylaws/privileges require board certification (I & R) Verify through ABMS Display Agents, AMA/AOA profile or specialty board NCQA Requirement Not Required (I & R) Verify through ABMS display agents, AMA/AOA profile, state licensing agency if board certified May not use ABMS consumer website (I & R) Lifetime certification must be documented 180/120 day time limit

NCQA Definitions 180/120 day time limit When document is submitted to Credentials Committee, verification date may not be older than 180 days. When CVO submits verification to Health Plan, verification date may not be older than 120 days. 365/305/180 Medicare Advantage - time limit When file is submitted to Credentials Committee, attestation date may not be older than 365 days. When CVO submits file to Health Plan, attestation date may not be older than 305 days. If physician on Medicare Advantage plan, attestation may not be older than 180 days.

Board Certification CMS Requirement No requirements Organization may not make decisions based solely on board certification – must consider all elements (license, training, experience, etc.) ABMS Display Agents, AMA Profile, AOA Profile HFAP Requirement Not required Membership and Privileges cannot be dependent solely upon certification, fellowship or membership in specialty body / society Must include other criteria, training, character, competence, judgment. Must document certification status and verification must include sanction information ABMS Display Agents, AOA Profile

Board Certification URAC Requirement Not Required Verify through ABMS display agents, AMA Profile, AOA Profile, state licensing agency if board certified (I) Verify at initial and upon expiration Six month time limit AAAHC Requirement Not Required PSV verify if organization requires board certification Continuous monitoring required – verify upon expiration

STATE LICENSE TJC Requirement (I & R) Primary source verification required at initial appointment, reappointment, revision/addition of privileges; also at expiration Verify through state licensing board NCQA Requirement Statement on application re: history of loss of license (I & R) Primary source verification thru state licensing board -required for all states where practitioner provides care License must be current when file presented to Credentials Committee NOTE: Utilize AIM DocFinder only if directed to site by state board 180/120 time limit

STATE LICENSE CMS Requirement HFAP Requirement Medical staff must have mechanism to verify current license No defined acceptable sources – assumption would be licensing board Silent regarding verification at time of expiration HFAP Requirement PSV required for all states where practitioner practices or intends to practice Also PSV all previous licenses held Telemedicine – must be licensed in state practitioner and patient are located

STATE LICENSE URAC Requirement PSV required Verification must include date of expiration, date verified and sanction status License must be current and valid when presented to Credentials Committee AAAHC Requirement PSV required Ongoing monitoring required

License Sanctions TJC Requirements NCQA Requirements (I & R) The doctor must provide information regarding challenges to licensure or registration & voluntary/involuntary relinquishment of license or registration Info must be evaluated before recommending privileges TJC silent on verification - May be verified thru licensing board NPDB or FSMB NCQA Requirements (I & R) Primary source verification of sanctions, restrictions on licensure, limitations on scope of practice for past five years in all states where applicant licensed Verify through state license board, NPDB,FSMB,HIPDB 180/120 time limit

License Sanctions HFAP Requirement CMS Requirement Not addressed HFAP Requirement (I) PSV of license sanctions for all current licenses, state of current practice or intended practice, all previous licenses held (R) PSV all current licenses Include previously successful and/or currently pending challenges to license; voluntary/ involuntary relinquishment of license NPDB & FSMB or FACIS

License Sanctions URAC Requirement List all current and historical licenses/sanctions on application PSV required for past five years practice history AAAHC Requirement List current/past license revocation, suspension, voluntary status, probationary status on application PSV and review at initial and reappointment

Malpractice Insurance TJC Requirements Not Required Primary source verification not required unless required by bylaws. (I & R) Verify through carrier or by current copy of policy showing dates and amount of coverage NCQA Requirement Primary source verification not required (I & R) Attestation by doctor, or policy face sheet showing dates and amount of coverage 365/305/180Medicare Advantage - time limit

Malpractice Insurance CMS Requirement Not required PSV not required HFAP Requirement PSV not required unless stated in bylaws (I & R) Verify through carrier or by current copy of policy showing dates and amount of coverage

Malpractice Insurance URAC Requirement Copy of cover sheet or attestation required for proof of insurance; must include name of practitioner, expiration date, and liability covered. If cover sheet does not include the name of the practitioner, then a copy of those covered under plan should be printed on insurer's letterhead and attached to cover sheet. AAAHC Requirement Evidence of policy if required by organization Applicant provides evidence of refusal or cancellation of coverage at initial and reappointment

Malpractice History TJC Requirement (I & R) Applicant must provide information regarding claims history (at a minimum must include final judgments/settlements) (I & R) Medical Staff must evaluate evidence of unusual pattern or excessive # of actions resulting in final judgment May verify with carrier or NPDB NCQA Requirement (I&R) Doctor must provide malpractice history for past five years. Five years history verified through carrier or NPDB (self query info from applicant not acceptable) 180/120 time limit

Malpractice History CMS Requirement Not addressed in standards HFAP Requirement 5 year history evaluated Malpractice history required from carrier or NPDB

Malpractice History URAC Requirement Organization defines time frame for history that must be provided by applicant and then evaluated Malpractice history (settlements and final judgments required from carrier or NPDB AAAHC Requirement Applicant must provide claims history on application Organization must evaluate

Work History TJC Requirement NCQA Requirement Term not used, However, evidence of current competence is required Organization should obtain information regarding licensure, education, training, experience and competence. NCQA Requirement (I) Doctor must provide five year work history on application or CV (should include month and year in all dates) No verification required but must explain gaps of 6 months or more verbally or in writing; if gap more than one year must explain in writing 365/305/180

Work History CMS Requirement Terminology not addressed in standards However, examination of experience and competence is required HFAP Requirement Applicant must provide healthcare employment and affiliation PSV required to include pending investigations, disciplinary actions, voluntary resignations, relinquishment of memberships/privileges/contracts

Work History URAC Requirement Not specifically addressed AAAHC Requirement Applicant to provide work history with explanation of time gaps Experience reviewed for continuity and relevance

CURRENT COMPETENCE Initial Application - TJC Primary source verification from post graduate training facilities, hospitals or other relevant organizations Must contain informed opinions of applicant’s professional performance Can use peer reference if specific questions about competency included on verification form Should include information about six general competencies

ACGME/ABMS - Six General Competencies Patient Care Medical/Clinical Knowledge Practitioner-based learning and improvement Interpersonal and communication skills Professionalism Systems-based practice