Credentialing

Contents Overview of Credentialing Generic Credentialing Process Accreditation Credentialing in Provider Organization Credentialing in Payor Organizations Delegated Credentialing-Credentialing in CVO Certifications on credentialing Potential Business Areas My Credentialing Model

Overview oF Credentialing

Credentialing/ Privileging This Process Determines, Admittance or Rejection of a provider into a Healthcare Organization For existing Affiliated practitioners: It serves to reassess the individuals continued appropriateness for practicing in the institution “Recredentialing” Privileging: It is defined as authority given to practitioner to provide specific care service in an organization within well-defined limits, based on evaluation of the credentials and performance Select Competent provider Assessing qualification Verifying Obtaining Information

PSV and Ongoing Monitoring Primary Source Verification It is a process through which an organization validates credentialing information by contacting the organization that originally issued the credentialing elements to the practitioners E.g.: The state dept that issues license to a practitioner is the primary source for verification of the validity of that license. Ongoing Monitoring Provider who are admitted into the organization are subjected to on going monitoring and valuation to ensure competence. Renewal of Credentialing (Recredentialinng) Renewal of privileges

Snap Shot of Credentialing in US More than 5,000,000 US practitioner Credentialed by more than 150,000 Healthcare Organizations In accordance with 50 individual state requirements As well as JACHO NCQA, URAC, CMS, AAAHC, HFAP As well as individual Organizational thresholds for review Accreditation Association for Ambulatory Health Care Healthcare Facilities Accreditation Program

Why Credentialing? Why do we do credentialing…? The primary purpose for credentialing is to ensure and promote quality service to patients Choose competent & Qualified providers A Study found 73% of the most severe injuries caused by the providers were preventable. One of the solution is Stricter Credentialing of LIP Along with ongoing monitoring A case of Negligent Credentialing: In Mid-1980 a local doctor performed a erroneous surgery on a child and he died. It was found during the trial that the provider was never granted a surgical privilege. At trial, the hospital was found to be 18% negligent and the doctor 82% negligent. The Verdict was 10 million dollars.

Regulatory Requirements Standards & requirements Driving Force Quality Case Laws Regulatory Requirements Accreditation Standards & requirements Risk Management Customer & Payor Expectations

1900’s 1970’s 1980’s 1990’s 2000 Evolution of credentialing American College of Surgeons created basic standards physicians and surgeons Foundation for credentialing process was set 1970’s Joint Commission Hospital Accreditation program They set accreditation credentialing standards 1980’s Primary source verification, Reappointment process Computers replaced electronic typewriters Health Care Quality Improvement Act verification service offered by Medical societies National Committee for quality Assurance (NCQA) 1990’s Beginning of online verification services Required use of National practitioner Data Bank (NPDB) MCO’s started to Delegate credentialing activities to IPAs, Hospitals or CVOs 2000 CAQH- Council for affordable Quality Heath care Outsourcing the work to foreign countries begun

Credentialing Happens During Who is credentialed? Who is Credentialed? Credentialing Happens During Individual Providers Participation Membership Affiliation Certification Privileges E.g.: Doctor , Nurse, Dentist… etc Whom to be credentialed is determined by: Accreditation standards Eligibility for affiliation/membership/privileges Internal process ( Bylaws, Policies..etc) State and Federal Laws. Healthcare Organizations E.g.: Hospitals, Rehab…etc

Laws that Affect Credentialing process State Laws Antidiscrimination Any-Willing-Provider Licensure Peer Review Disclosure of selection criteria Economic Profiling Federal Laws American with Disabilities Act Health Care Quality Improvement Act Medicare Conditions of participation Health Maintenance Organizations Act Text Case Laws Laws That Affect Credentialing

Generic Credentialing Process

Basic Credentialing Process Steps APPLICATION Identification of practitioner/provider Prescreening Completion of application Return application to processing org Recredentialing every two years VERIFICATION AND INFO GATHERING Credentials file is developed as data and info are collected All or part of verification may be outsourced or delegated ANALYSIS Review and evaluation of information in file DECISION And notification to applicant Monitoring and evaluation

Elements which are verified Website Image Mail/Fax/E-mail Phone call Electronic Query DEA - CDS PLI State License Board Education Work History Hospital Affiliations Medicare/Medicaid Opt out OIG GSA NPDB HIPDB FSMB

OIG and GSA OIG The Department of Health and Human Services Office of Inspector General maintains a list of sanctioned individuals. Most OIG Sanction reports pertain to individuals – such as a specific practitioner. It includes any action taken on Fraud, Waste, Mismanagement, Abuse, and Corruption GSA The United States General Services Administration (GSA) oversees contracts with the Federal government. They maintain a list of parties excluded from doing business with the Federal government, including healthcare programs receiving Federal funding or reimbursement Most GSA Excluded Parties are vendors or corporations, but some may be individuals with their own businesses. Healthcare Integrity and Protection Data Bank (HIPDB) The Healthcare Insurance Portability and Accountability Act of 1996 directed the creation of the Healthcare Integrity and Protection Data Bank (HIPDB). The purpose of HIPDB is to combat fraud and abuse in health care insurance and health care delivery. HIPDB is a national data collection program for the reporting and disclosure of certain final adverse actions taken against healthcare providers, suppliers and practitioners. The following types of actions are included in HIPDB: Civil judgments in State or Federal court related to the delivery of a health care item or service Federal or State criminal convictions related to the delivery of a health care item or service Actions by Federal or State licensing and certification agencies Exclusions from participation in Federal or State health care programs Any other adjudicated actions or decisions as established in regulations.

NPDB and HIPDB Healthcare Integrity and Protection Data Bank (HIPDB) National Practitioner Data Bank(NPDB) The purpose of HIPDB is to combat fraud and abuse in health care insurance and health care delivery. HIPDB contain adverse actions taken against healthcare providers, suppliers and practitioners The following types of actions are included in HIPDB: Civil judgments Criminal convictions Actions by Federal or State licensing and certification agencies Exclusions from participation in Federal or State health care programs Other adjudicated actions or decisions as established in regulations. The National Practitioner Data Bank (NPDB) was created by the Health Care Quality Improvement Act of 1986 to track information on physicians and dentists. The following types of actions are included in NPDB: Adverse licensure actions Clinical privileges actions Professional society actions Medical malpractice payments made on behalf of all health care practitioners, including nurses. National Practitioner Data Bank/Healthcare Integrity and Protection Data Bank The National Practitioner Data Bank (NPDB) was created by the Health Care Quality Improvement Act of 1986 to track information on physicians and dentists. To encourage the peer review process identify incompetent or unprofessional practitioners To restrict their ability to move from state to state without disclosure or discovery of previous damaging or incompetent practice The NPDB contains information on adverse action taken on physician and dentist. It includes: adverse licensure actions clinical privileges actions professional society actions the NPDB collects reports of medical malpractice payments made on behalf of all health care practitioners, including nurses. Healthcare Integrity and Protection Data Bank (HIPDB) The purpose of HIPDB is to combat fraud and abuse in health care insurance and health care delivery. HIPDB contain adverse actions taken against healthcare providers, suppliers and practitioners The following types of actions are included in HIPDB: Civil judgments in State or Federal court related to the delivery of a health care item or service Federal or State criminal convictions related to the delivery of a health care item or service Actions by Federal or State licensing and certification agencies Exclusions from participation in Federal or State health care programs Any other adjudicated actions or decisions as established in regulations.

Accreditation

Accreditation Accrediting Bodies Accreditation is an evaluation process in which a healthcare organization undergoes an examination of its operating procedures To determine whether they meet designated criteria To ensure that the organization meets specific level of quality. Accreditation Adds value to the Organization It acts as an External seal of approval Promotes quality improvement Accrediting Bodies NCQA URAC JACHO AOA CARF AMAP

Accrediting Bodies JACHO Joint Commission on Accreditation of Healthcare Organizations ( Joint Commission) The American College of Physicians, The American Hospital Association, The American Medical Association and Canadian medical Association joined with the American College of surgeons to form Joint Commission They have introduced ORYX. Scope of service: Ambulatory care Behavioral healthcare Home Care Hospital Long-Term Care Health Care network Clinical Laboratory Preferred provider Organization URAC URAC is a non-profit, charitable organization that has issued over 1,600 accreditation certificates to more than 300 managed care organizations Doing business in all 50 states. URAC has over 16 accreditation and certification programs Scope of service: Hospitals HMOs PPOs TPAs Provider groups NCQA They have 8 accreditation programs and certification programs They have also introduced the HEDIS and CAHPS Scope of Service: Managed Care Organizations Managed Behavioral Health care Organizations Credentialing Verification Organizations Physician Organizations New Health Plan The URAC Credentialing Support Certification (CSC) standards are designed for international and domestic organizations that gather data for provider networks and CVOs in order to verify the credentials of health practitioners.

Organization that Credential HMO PPO POS CVO Hospitals IPA CVO Payor Organizations Provider Organizations

Credentialing IN Provider Organizations HOSPITAL CREDENTIALING HMO PPO POS CVO Hospitals IPA CVO Payor Organizations Provider Organizations

Credentialing in Hospital Credentialing in hospital is performed by Medical Staff Coordinator Medical Staff Coordinator do credential verification during: Initial Appointment Re-appointment Privileges Re-privileges Bylaws of medical staff organization includes description and responsibilities of Qualification for medical staff membership Categories of medical staff Medical executive committee Medical staff departments Credentials committee

Credentialing in Hospital Yes

Credentialing IN PAYOR Organizations MCO CREDENTIALING HMO PPO POS CVO Hospitals IPA CVO Payor Organizations Provider Organizations

Payor Organization-MCO Managed Care Organization integrate the financing and delivery of healthcare within a system. To Ensure health plan member access to MCO’s credential Facility that provides healthcare services Facilities that are Credentialed include: Ambulatory services Birthing Centers Durable medical equipment provider Hospitals Sleep Study Centers Necessary Services Provide high quality care Improve cost effectiveness of care delivery

+ MCO = New Math Network Of Providers Contract -------------- Characteristics of Managed Care Organizations: A panel of affiliated or contracted practitioners and providers Limitation of benefits if a non-contracted provider is used An authorization system

Ways through which credentialing is handled Credentialing In MCO In-House Credentialing Quality Management Function Provider Relations Rep In-house credentialing Dept Delegated Credentialing CVO Hospital IPA Other provider organizations

Organizational Structure of an MCO

Basic Steps for credentialing in MCO 1 Market Analysis 2 Define scope of service 3 Design the panel size 4 Identification of potential Providers 5 Collect and verify provider’s credentials 6 Analysis and decision 7 Recredential-ing 8 Maintenance and problem resolution

Credentialing Process in MCO Delegation of credentialing Process to another Organization for Specified Practitioners and /or Providers Preapplication Application Delegation of Verification to a CVO Verification Information Gathering File development Office Evaluation Review and Approval or decline to credential Medical Record Review Rrecedential

Structure of Credentialing Process Activity Accountability Data Collection and File Maintenance Credentialing Staff Review and Recommendation Credentialing Committee or Review Body Medical Director Approval ( May be delegated to credentials Committee/ Administration/ Medical director by governing Board) Governing Board Provider Relations / Contracting Contract or Letter of Agreement After Initial Credentials Approval

Office evaluation & Medical Record Review Office evaluation is handled by the recruiter or a well trained Nurse They evaluate the provider's office on: Capacity to accept new members Office Ambiance Quality management Compliance with Health Administration guidelines Presence of certain type of equipment (e.g. defibrillator) Cleanliness of the office Friendliness of the staff towards patient General atmosphere Medical Record Review Medical director review a sample of medical record Purpose of this review is to assure, Physician practice high-quality medicine His practice is already cost effective

Difference in credentialing activity between Hospital and MCO Number of Practitioners credentialed Scope Bylaws Versus Contracts Accrediting Organizations and standards Appointment Privileging Physician Office Site visits and Medical Record Review

Delegated Credentialing -Credentialing IN CVO HMO PPO POS CVO Hospitals IPA DELEGATED CREDENTIALING CVO CREDENTIALING CVO Payor Organizations Provider Organizations

Delegation Delegation is a formal process through which a Healthcare organization transfers to another entity the authority to conduct certain functions on behalf of the health plan. It is governed by various accrediting and regulatory bodies and by state laws To reduce the risk of delegation the delegating entity establish a formal program for oversight of delegated function Oversight of the delegated activities is done by: The Credentialing Committee Quality Management Committee Utilization Management Committee The entity that contracts with the MCO to perform the specified function is the delegate

Activities that are delegated Activities that are delegated by an MCO Credential Verification Medical Record Review Site review Peer Review Activities that are delegated by a Hospital or a provider organization Filling of provider’s Application Credentialing Verification Peer review

Potential Delegates Potential Delegates of an MCO Hospitals and Other facilities Provider Organizations Credential Verification Organization Potential Delegates of a Hospital Practice management organizations

CVO CVO: Credential Verification Organization They link providers to hospitals and managed care organizations They do the credential verification on provider’s, behalf of healthcare organization Services Offered by a CVO: Primary source Verification Distribution of Application and reapplication to practitioners Oversight and follow up on proper completion of application File maintenance of time sensitive documentation track expiable like license renewals and recredentialing deadlines, and support through routine NCQA/URAC compliance audits. Monitoring of licensure and government Agency sanctions

CVO over In-House Credentialing Managed care organizations and other Healthcare Organizations have long depended on CVOs to provide credentialing services because Lowering their liability Offer better turnaround time Lower overhead and expense Reduced staff time of managed care groups Lower liability to managed care groups Lessen the risk of penalties for errors during NCQA/URAC audits. Help reduce staff time and training Any problems with a provider will be notified immediately to the managed care organization’s review committee. They offer extra services, such as tracking expirables like license renewals and recredentialing deadlines, and support through routine NCQA/URAC compliance audits.

CVO Organizational Chart

Credentialing process in a CVO MCO sends request for credentialing / recredentialing CVO’s do not have authority to accept or reject a provider from network They only Collect and very the credentials of the provider and Send a report to the MCO or other organization, on the provider’s credentials CVO Send’s app to provider Is Application received NO Yes Is Application Complete NO Yes Send a report on the provider to the MCO Verify the provider’s credentials

Additional Info on Credentialing DISASTER CREDENTIALING CENTRALIZED APPROCH TO CREDENTIALING INFORMATION TECHNOLOGY BOOSTS CREDENTIALING

Disaster Credentialing Post 9/11 JACHO developed “Disaster credentialing” Disaster privileges may be granted when the emergency management plan has been activated When the organization is unable to handle the immediate patient needs Verification of the credentials and privileges of individuals begins as soon as the immediate situation is under control

Centralized Approach to Credentialing To avoid replication of credentialing process Reduce Administrative cost Efficient credentialing Examples for centralized credentialing approach CAQH ABMS OneSource Federal Credentialing Program (FCP)

Information Technology Boosts Credentialing Helps Streamline otherwise tedious credentialing Verification of credentials made online Online Applications Software to generate same provider’s info into organization specific application Maintaining of massive amount of information storage Speedy access of information Helps reduce Turnaround time Paperless credentialing reduces Administrative cost

Certifications CERTIFICATION TO BECOME A PROFESSIONAL CREDENTIALER

Certification on Credentialing CPCS CPMSM Certified Professional Medical Staff Management (CPMSM) Responsible for maintaining compliance with regulatory and accrediting bodies Developing and implementing credentialing process, procedures Overseeing development of and adherence to Governance by laws Department rules and regulations Medical staff Practitioner/provider policies May also be responsible for overall management of medical service functions (CPCS) Certified Provider Credentialing Specialist Participate in the development implementation of Credentialing process, procedures Governance by laws Department rules and regulations Medical staff Practitioner/provider policies Maintaining an accurate practitioners database Collecting and analyzing verification information CMSC (redirected from Certified Medical Staff Coordinator)

Potential Business POTENTIAL BUSINESS AREAS TOP CVOs TOP 10 MCOs

Potential Business Areas COGNIZANT Potential Business CVO MCO Ambulatory Care Org IPA / Hospitals

Potential Customers (CVOs) Medadvantage Providing credentialing services to MCO’s and MBHO’s in all 50 states, the District of Columbia Has databases of One Million medical practitioners and Six Million verifications Their IT partner Their BPO partner Medversant Web-based credentials verification includes over 800,000 providers in its Encompass™ platform MedVentive Founded as the internal CVO for the CareGroup Health System

Potential Customers Company Revenue Total Enrollment Top 10 Publicly Traded MCO’s in US Company Revenue Total Enrollment United Health Group $20.2 Billion 30.3 Million Well Point Inc $15.3 Billion 35.3 Million Aetna Inc $7.8 Billion 17.7 Million Humana Inc $7.1 Billion 8.4 Million CIGNA Corporation $4.1 Billion 11.9 Million Health Net Inc $3.8 Billion 6.7 Million Coventry Health Care Inc $3.0 Billion 3.7 Million Ameri Group Corp $1.1 Billion 1.7 Million Centene Corp $897.1 Million 1.2 Million Molina Health Care Inc $791.6 Million

My Credentialing Model

My Credentialing Model GSA OIG Get excluded list every Month HIPDB MCO Buy verified info NPDB Query Send Hospital Roster CVO Provider app is downloaded CAQH Hospitals Buy Verified info Help CVO in verifying credentials. Authorize to release the info Fill app Reattest app (120 days) Providers

Questions

Thank You !