Complaints, Malpractice Coverage/PLI, Medicare/Medicaid Sanctions

Slides:



Advertisements
Similar presentations
Appendix L, Ambulatory Surgical Centers Comprehensive Revision
Advertisements

COMPARATIVE DIFFERENCES OF MEDICAL STAFF and CREDENTIALING STANDARDS
On The Fast Track Explore a two-track credentialing model using QEW/ECHO as the implementation tool Presented by Lisa Rothmuller.
CREDENTIALING Where does the Board fit in? Robert P. Redwine President, Board of Directors Blount Memorial Hospital Maryville, Tennessee.
Healthcare Facilities Accreditation Program (HFAP)
Disaster Credentialing– Help is on the Way Sandy Steigerwald, RN, BSN Harris County Medical Reserve Corps.
District of Columbia Health Benefits Exchange Authority Network Adequacy Working Group February 14, 2013 Chair: Diane Lewis Vice Chair: Stephen Jefferson.
Presentation before the Missouri Bar’s Health and Hospital Law Committee November 18, 2011 Markus P. Cicka, J.D., L.L.M. (Health Law) Director – Missouri.
The Health Insurance Portability and Accountability Act of 1996– charged the Department of Health and Human Services (DHHS) with creating health information.
Overview of Medicare Policies Keith Williams & Associates, Inc.
CAMSS The Complexities of Managed Care Credentialing Mei Ling Christopher, UnitedHealthcare Sallye Marcus, Anthem Blue Cross.
How to Prepare for a FTCA Site Visit Office Hours
Telehealth & Medicare Hospice Conditions of Participation Deborah Randall JD, Attorney/Telehealth Consultant,
Telemedicine Credentialing and Privileging October 16, 2014.
Hospital Patient Safety Initiatives: Discharge Planning
Chapter 10: Strategies to Reduce Liability. Managing Physicians Facilities may have liability when a physician is involved in malpractice –Respondeat.
Ron Wyatt MD, MHA, Merck IHI Fellow
1 What They Don’t Teach You in Medical School (Steps in Medical Staff Credentialing) March 13, 2008 Judi Smedra, CPMSM, CPCS Director, Medical Staff Affairs.
Establishing a Hospital Patient
Why the National Practitioner Data Bank Matters to You and Your Clients Mark V. Gende, Esq. Sweeny, Wingate & Barrow, PA Columbia, South Carolina.
Marianne Klaas, RN, MN, CHSP Swedish Medical Center Administrative Director Accreditation, Safety, Injury Management, and Clinical Patient Relations Contract.
DNV GL © 2014 SAFER, SMARTER, GREENER DNV GL © 2014 National Credentialing Forum Patrick Horine, MHA President & CEO DNV GL Healthcare.
2015 HFAP Standards CMS Final Rule – Burden Reduction II May 2014 Karen Beem, MS, RN HFAP Standards Interpretation 2015 National Credentialing Forum1.
Credentials Committee Orientation. Responsibilities of the Committee Review the credentials of all applicants to the Medical Staff and privileges requests.
© 2013 Federation of State Medical Boards. Handling Medical Complaints Fairly and Transparently J. Daniel Gifford, MD, Chair-Elect Federation of State.
TDCI TennCare Oversight Division Provider Complaint Process A Summary for TennCare Providers April 18, 2013.
Medical Law and Ethics, Third Edition Bonnie F. Fremgen Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved.
Debra R. Green, MPA, CPMSM, CPCS
NCQA Standards Update & Delegated Credentialing Tips NYSAMSS Annual Meeting – May 4, 2012 By: Di Hall, CPCS, CPMSM Director, Compliance & Quality Improvement.
Discount Medical Plan Organizations (DMPOs) David Foy Florida Office of Insurance Regulation January 25, 2006.
Audits Allegations Secret Shops Corrective Actions.
Credentialing in Every Environment 41 st Annual CAMSS Education Forum Patricia E. Brown, BSCJ, CPCS May 16, 2012.
U N C H E A L T H C A R E S Y S T E M Telemedicine Sarah Fotheringham, JD Associate General Counsel, UNC Health Care
The primary purpose of credentialing is to protect health care organizations from the legal liability that could result from the actions of unqualified.
1 Comparison of The Joint Commission and DNV- GL HC’s National Integrated Accreditation for Healthcare Organizations (NIAHO ℠ ) MS Standards Kathy Matzka,
Performing Credentials File Audits Kathy Matzka, CPMSM, CPCS.
Coordinating Medicare Benefit Integrity Adele Culpepper and Amy Miller-Bowman.
DNV GL © 2013 SAFER, SMARTER, GREENER DNV GL © 2013 DNV Healthcare – Top Survey Findings – Medical Staff National Credentialing Forum.
United Behavioral Health, operating under the brand Optum U. S. Behavioral Health Plan, California, doing business as OptumHealth Behavioral Solutions.
Telemedicine – Who, What, Why & Where Catherine Ballard, Esq., Executive Director The Quality Management Consulting Group, Ltd. and Partner, Bricker &
NUR 607 Credentialing & privileging. Significance of these activities Initial Ongoing Ensure protection of the public Autonomy and independence of the.
DNV GL © SAFER, SMARTER, GREENER DNV GL © National Credentialing Forum DNV GL- Healthcare Patrick Horine, MHA President and CEO.
Credentialing: 2017 Updates and Frequently Asked Questions
Collaborative Practice Agreements
2017 January – July Proposed Bylaws Revisions
PROPOSED BYLAW REVISIONS NOVEMBER 2015
Diana K. “Di” Hall, CPCS CPMSM – Sr. Director, Compliance & Quality
Establishing and Understanding a CVO
Designing Effective Accommodation Plans in Clinical Placement & Internship Settings
Crouse Health Hospital
Privacy principles Individual written policies
Disclaimer This presentation is intended only for use by Tulane University faculty, staff, and students. No copy or use of this presentation should occur.
IAMSS 2018 Education Conference April 12, 2018
An Analysis of Our Medical Staff
CERTIFICATION FOCUSED STUDY PROGRAM
Medical Credentialing
Sponsored by the Mass Collaborative, MHA, MMS, and MAMSS
Practitioner Hospital Data Bank
MAMSS Delegated Credentialing Panel May 19, 2016
NATIONAL CREDENTIALING FORUM FEBRUARY 20, 2004
GHS Medical Staff Appointments and Reappointments
Delegated Credentialing: Do You Know Where to Start?
Patient Rights & Responsibilities – Part II
North Carolina Association Medical Staff Services MAY 15, 2008
Things that make you go Hmmmm?!
OBJECTIVES DISCUSS CREDENTIALING AND WHY IT IS IMPORTANT
Health Status, Identity, Board Certification, CME
NAMSS Standards Criminal Background Check, DEA, Education, Licensure/Sanctions, Residency/Fellowship.
Appointment Timeframes, NPDB, Site Visit, Temporary Privileges
NAMSS Standards Attestation Statement, Current Competence, Peer Recommendation, Work History.
Presentation transcript:

Complaints, Malpractice Coverage/PLI, Medicare/Medicaid Sanctions NAMSS Standards Complaints, Malpractice Coverage/PLI, Medicare/Medicaid Sanctions

Complaints TJC - There must be a process for evaluation of the credibility of a complaint, allegation, or concern against a privileged provider. NCQA - Must continually monitor member complaints for all practitioner sites. There must be a process to monitor and investigate member complaints related to the quality of all practitioner office sites and must conduct site visits for complaints related to physical accessibility, physical appearance and adequacy of waiting- and examining-room space if the organization’s complaint threshold is met.

HFAP - Data collected regarding patient grievances and complaints that are not defined as grievances are reviewed through the QAPI functions. DNV - The hospital must develop and implement a formal grievance procedure, which includes a referral process for quality of care issues to the Utilization Review, Quality Management or Peer Review functions, as appropriate. URAC - There must be a mechanism for conducting additional review and investigation of credentialing applications in cases where the credentialing process reveals factors that may affect the quality of care or services delivered to consumers. Parameters or triggers of potential quality of care issues that require further investigation must be included in a policy.

AAAHC - Risk management process includes an ongoing review of patient complaints and grievances that includes defined response times, as required by law and regulation. Medicare CoP’s - The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.

Malpractice Coverage/PLI TJC - Not addressed. However, if the medical staff bylaws/ rules/regulations require malpractice coverage, it is expected that the organization have a method to verify such coverage. NCQA - The application form must include specific questions regarding the dates and amount of a practitioner’s current malpractice insurance or the organization may obtain a copy of the insurance face sheet from the malpractice carrier. HFAP - Must have evidence of professional liability insurance including current certificates showing amount insurance.

DNV - Medical staff criteria for consideration of automatic suspension includes when the practitioner has failed to maintain the minimum specified amount of professional liability insurance as required in the medical staff bylaws. URAC - Proof of liability insurance included on application. AAAHC - Documentation of professional liability insurance present if required by the organization. Monitored on appointment, reappointment, expiration and on an ongoing basis). Information regarding refusal or cancellation of professional liability coverage provided by the applicant reviewed at initial and reappointment. Medicare CoP’s - Not specifically addressed.

Medicare/Medicaid Sanctions TJC and Medicare CoP’s – Do not address NCQA - Verification of past Medicare/Medicaid sanctions may be done through a query HFAP - The application requests information regarding disciplinary actions taken or investigations pending by Medicare/Medicaid. DNV - Bylaws provide a mechanism for immediate and automatic suspension of privileges due to the termination or revocation of Medicare or Medicaid status. OIG Medicare/Medicaid Exclusions verified at initial, reappointment, and when granting temporary privileges.

URAC - Required to be reported on application URAC - Required to be reported on application. Can verify with issuing organization or NPDB. AAAHC - Information concerning Medicare/Medicaid sanctions disclosed and evaluated on initial and reappointment.