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.

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Presentation transcript:

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 The University of Kansas Hospital

2 CREDENTIALING Process of obtaining, verifying, and assessing the qualifications of a healthcare practitioner to provide patient care services in or for a healthcare organization

3

4 WHO’S WATCHING YOU NOW? The Joint Commission (H) National Practitioner Data Bank (H) Managed Care Organizations (H) Hospital Boards (Ultimate Authority) (H) CMS (Medicare) Medicare/Medicaid State Professional Review Organizations State Board Of Healing Arts Managed Care Accrediting Agencies (M) Credentials Committee (Final Decision) (M)

5 WHAT ARE THEY LOOKING FOR? Quality Patient Care Efficient Patient Care Length Of Hospitalization Legible Charts Medical Records Compliance Citizenship (H) Privileges Requested Match Privileges Performed (H) Continuing Medical Education (CME) Pertains To Specialty (H)

6 APPLICATION PROCESS – WHAT TO EXPECT Group Practice Dictates Where You Practice & How to Obtain Application Be Complete & Accurate Privileges / Membership Will Not Be Granted Overnight! Expect Application Fee and/or Dues

7 APPLICATION PROCESS – MAKE IT EASY ON YOURSELF! Account for All Time Periods – Month & Year (must document gaps > 30 days) Training Affiliations / Work History Insurance Carriers State Licenses

8 APPLICATION PROCESS – MAKE IT EASY ON YOURSELF! (continued) References (must be in your specialty) Medicare/Medicaid Provider Numbers NPI (National Provider Identifier) Signed Attestation / Release (authorization)

9 PRIVILEGES Will Be Required To Produce Documentation Of Training And/Or Experience Proctoring May Be Required For Specified Time Period Or Number Of Procedures

10 DOCUMENTATION CHALLENGES Curriculum Vitae Dates (include Month & Year) Identify Custodian of Records for Closed Training Programs/Affiliations Licensure Kansas – Postgraduate License Missouri – Temporary License for Training Diplomas / Certificates Medical School, Training Programs, Boards

11 DOCUMENTATION CHALLENGES (Continued) DEA Certificate Prescribe/Administration of Drugs Kansas/Missouri BNDD Change of Address Case Log Photograph For Identity Compliance Training/Exams (HIPAA,Privileges)

12 PRIMARY SOURCE VERIFICATION Direct Contact With Sources To Guarantee That Statements Are Legitimate, Unchallenged & Appropriate

13 TYPICAL VERIFICATION Completed Application - All Activity from Medical School to Present AMA OR AOA Profile Verification Of All Licensure Training & Competency Board Certification ECFMG (If Applicable) Criminal Background Check Malpractice Claims History

14 TYPICAL VERIFICATION (Continued) Group Practice Affiliations NPDB Report (H) – HIPDB Report (M) Peer References Office Of The Inspector General General Services Administration Timeframe Burden Of Proof Is On You!

15 REAPPOINTMENT Provisional / Probationary (H) Joint Commission – Every Two Years (H) NCQA (Managed Care Organizations) – Every Three Years (M)

16 MEDICAL STAFF COORDINATOR Your Best Friend or Worst Nightmare – Your Choice!