Medical Staff Credentialing and Peer Review – Common Mistakes Debbie Comerford RN BSN CNOR CASC

OBJECTIVES DISCUSS CREDENTIALING AND WHY IT IS IMPORTANT DRILL DOWN ON SOME ASPECTS OF CREDENTIALING THAT ARE PROBLEMATIC DURING SURVEY DISCUSS PEER REVIEW

INTRODUCTION Credentialing files are reviewed by every agency: Accreditation State licensing CMS Important that files be up to date at all times Organized Separate out discoverable items from confidential items that you don’t want anyone to see Always keep original application and approval documents in the current file Consider thinning the file every 3 years Accreditation requirement is that no lapse has occurred during the cycle.

What is credentialing and why do we do it? §416.45(a) Standard: Membership and Clinical Privileges Members of the medical staff must be legally and professionally qualified for the positions to which they are appointed and for the performance of privileges granted. The ASC grants privileges in accordance with recommendations from qualified medical personnel. Legally qualified:

CREDENTIALING Credentialing is a three-phase process of assessing and validating the qualifications of an individual to provide services. The objective of credentialing is to establish that the applicant has the specialized professional background that he or she claims and that the position requires. Establishes minimum training & experience Establishes a process to follow to evaluate an individual’s qualifications Carries out the governing body approved review process as described Discuss bylaws

1. Establish Minimum Training, Experience, and Other Requirements: Medical Staff Bylaws Defines the specific process for credentialing in your organization Process for initial appointment & reappointment Process of granting privileges Process for suspending or Terminating clinical privileges Appeal process Include process for initial appointment & reappointment Complete a written application and provide the supporting documents for review: Licenses, insurance coverage, education history, CV, attestations, and authorization for release of information provided by the applicant Complete a list of requested privileges Include individual lasers, local anesthesia administration, supervision of anesthesia and surgical services, Operation and interpretation of C-Arm and radiographs, use of ultrasound devices in specialties Granting of privileges process: Who reviews the information to determine if the applicant meets the organization’s established criteria. Required items to be included in the review are: Education – may be verified through the AMA Profile service or through each institution There is a cost for this to the organization Peer evaluation: Initial appointment – peer references attesting to the applicants competence Reappointment: Peer review summary Current state license, DEA license, CDS Liability coverage verification National Practitioner Data Bank information Attestation regarding Professional liability claims history, license action, complaints from national local societies, cxl of insurance, denial, suspension, limitation to professional privileges, action on DEA, Medicare Medicaid sanctions, conviction of criminal offense, and current physical and mental health, or chemical dependency problems. Application must be signed and dated Suspending or Terminating clinical privileges Appeal process

2. Establish a process to follow to evaluate an individual’s qualifications The bylaws should describe how the application and requested privileges are handled: Who reviews it? Medical Director Who approves it? Governing board Timeframe to approval Not specific, but timely What happens if the application is denied Written process for appeals

3. Carries out the review process as described This is the actual “credentialing” and completes the process Verify all of the submitted documentation Primary sources of verification for licenses: http://www.op.nysed.gov/opsearches.htm#nme Primary Source verification of DEA https://apps.deadiversion.usdoj.gov/webforms/validateLogin.jsp Medicare/Medicaid Sanctions: SAM – now requires a notarized letter to authorize your entity https://www.fsd.gov/fsd-gov/home.do OIG/EPLS (Prevent fraud & abuse in Medicare/Medicaid) https://exclusions.oig.hhs.gov/ Contact insurance carrier to provide a claim history

3. Continued National Practitioner Data Bank Query response Register your entity with the Data Bank – don’t use another organization’s Data Bank ID Enroll in continuous query option: Monthly reports on your enrollees Accepted by accreditation organizations Saves time Keep the monthly correspondence with credentialing files in its own file Keep the reports confidential Keep the summary in the file and the report in a separate file There is no need for a surveyor or inspector to review the confidential information in your reports on your providers. They are only validating that your organization queries the data bank, not what you find. The reports are only to be used and read by persons authorized to do so – for appointment, reappointment, and peer review.

Information reported to the NPDB is considered confidential and will not be disclosed except as specified in the NPDB statutes (Title IV, Section 1921, and Section 1128E) and implementing regulations (45 CFR Part 60). Confidential receipt, storage, and disclosure of information are essential ingredients of NPDB operations. The confidentiality provisions of Title IV, Section 1921, and Section 1128E allow an eligible entity receiving information from the NPDB to disclose the information to others who are part of an investigation or peer review process, as long as the information is used for the purpose for which it was provided. In those instances, everyone involved in the investigation or peer review process is subject to the confidentiality provisions of the NPDB.

Privileging 23% of all Medicare Deemed Status ASC’s surveyed by AAAHC in 2017 were deficient in the area of Privileging {416.45(a)} Common problems Expired appointments Expired privileges Lack of privileges for specific procedures performed Expired date sensitive items Lack of peer review as part of reappointment

EXPIRED APPOINTMENTS 1. CMS recommends reappointment every two years Where is the information addressing credentialing kept? Know your bylaws Follow your organization’s state regulations and by- laws Initial appointment timeframe Temporary Privileges Active Appointment If performing the credentialing paperwork on site Perfect world: All providers are done together every two years Not so perfect: Batch them together over time Create a calendar reminder for all date sensitive items including appointments, licenses, DEA, CD, malpractice insurance etc.

PEER REVIEW Initial appointment should require at least 2 peer references. Follow your written bylaws when obtaining peer references. If your bylaws state you will obtain three, then you should have three. Obtain a written reference using a standardized format Send out at least one more request than you need Obtain peer references’ emails on the application Follow up with the references as needed Peer references often are the last thing to get and hold up the process, especially if using a CVO

PEER REVIEW FOR REAPPOINTMENT Each physician or dentist receives peer-based review from at least one similarly-licensed peer. The organization provides ongoing monitoring of important aspects of care provided by physicians, dentists, and other health care professionals. The results of peer review are used as part of the process for granting continuation of clinical privileges. Peer to peer review means similar licenses: a physician of one specialty is able to review a physician from another specialty – an example is an anesthesiologist is able to review a pain management physician. It is not ideal, but when there is only 1 physician within a specialty, they can be reviewed by another physician on the medical staff. Solo practitioners must send out peer review to outside, and still need to complete it. A CRNA is not able to review an MD, but an MD can review a CRNA. A PA cannot review a surgeon, but a surgeon can review a PA. Allied Health providers must also receive peer review – different criteria than surgeon

Summary of Peer Review It is helpful to use a one page summary sheet at each reappointment cycle to indicate : the number of cases performed during the period number of cases reviewed randomly number of cases requiring review due to complications, infections, and other problems any practice concerns that have been addressed Review and approval by the Governing Board and Medical Director of the peer review summary CRITERIA WILL BE DIFFERENT FOR SURGEONS, ANESTHESIA PROVIDERS, AND ALLIED HEALTH PROFESSIONALS. They all require peer review as part of the medical staff.

PEER REVIEW Ongoing chart review completed by peers, not the nursing staff, is one part of peer review, but not the only part 100% of all complications, infections, unexpected occurrences should be reviewed Criteria is determined by your organization’s physicians Infections Complications Return to OR Improper drug utilizations Transfers Sentinel events Malpractice claims Complaints by staff or patients Return to OR – unplanned Legibility of handwriting (illegibility) Lack of adherence to hand hygiene policy Lack of adherence to safe injection policy

CONCLUSION Keep files neat Follow your bylaws and policy for credentialing Keep date sensitive items current Perform peer review on an ongoing basis Summarize peer review for reappointment Create a reminder for date sensitive items so they do not expire, including privileges, appointment, licenses, and malpractice insurance coverage Always be survey ready