Understanding CMS Requriements for Credentialing and Privileging 4/21/2017 12:03 AM Understanding CMS Requirements for Credentialing, Recredentialing, and Privileging in Hospitals and Managed Care Kathy Matzka, CPMSM, CPCS 1304 Scott Troy Rd, Lebanon, IL 62254 (618) 624-8124 kathymatzka@kathymatzka.com www.kathymatzka.com © 2007 Microsoft Corporation. All rights reserved. Microsoft, Windows, Windows Vista and other product names are or may be registered trademarks and/or trademarks in the U.S. and/or other countries. The information herein is for informational purposes only and represents the current view of Microsoft Corporation as of the date of this presentation. Because Microsoft must respond to changing market conditions, it should not be interpreted to be a commitment on the part of Microsoft, and Microsoft cannot guarantee the accuracy of any information provided after the date of this presentation. MICROSOFT MAKES NO WARRANTIES, EXPRESS, IMPLIED OR STATUTORY, AS TO THE INFORMATION IN THIS PRESENTATION. Kathy Matzka, CPMSM, CPCS 1

Understanding CMS Requriements for Credentialing and Privileging CMS Hospital CoPs All Interpretative guidelines and manuals are on website Rev. 137, 04-01-15 (most recent hospital) http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf Rev. 110, 10-10-14 – most recent CAH http://cms.hhs.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_w_cah.pdf Most recent rule changes for MS posted in Federal Register May 12, 2014 http://www.gpo.gov/fdsys/pkg/FR-2014-05-12/pdf/2014-10687.pdf Kathy Matzka, CPMSM, CPCS

CMS Hospital Page http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Hospitals.html

Surveyor & Certification Memos http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions.html

Document Review – Hospital and CAH Medical Staff Bylaws , Rules & Regulations Credential files to determine if the facility complies with CMS requirements and State law, as well as, follows its own written policies for medical staff privileges and credentialing Personnel files to determine if staff members have the appropriate educational requirements, have had the necessary training required, and are licensed, if it is required (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

Medicare Conditions of Participation Hospital and CAH CoPs require criteria for determining privileges and for applying the criteria: Individual character Individual competence Individual training Individual experience Individual judgment (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

Hospital Sec. 482.22(a) – MS Composition The medical staff must be composed of MDs and DOs In accordance with State law, including scope-of-practice laws, the medical staff may also include other categories of physicians (as listed at § 482.12(c)(1) MD/DO/DDs/DMD/DPM/DC/OD) and non-physician practitioners who are determined to be eligible for appointment by the governing body. (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

Hospital IG - §482.12(a)(1) For physician practitioners granted privileges only, the hospital’s governing body and its medical staff must exercise oversight, such as through credentialing and competency review, of those other physician practitioners to whom it grants privileges, just as it would for those practitioners appointed to its medical staff CMS expects that all physician practitioners granted privileges are also appointed as unless State law limits the composition of the hospital’s medical staff to certain categories of practitioners (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

Survey Procedures §482.12(a)(1) Review documentation and verify that the governing body has determined and stated the categories of physicians and practitioners that are eligible candidates for appointment to the medical staff or to be granted medical staff privileges. (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

Hospital IG §482.12(a)(1) Other types of licensed healthcare professionals have a more limited scope of practice and usually are not eligible for hospital medical staff privileges, unless their permitted scope of practice in their State makes them more comparable to the above listed types of non-physician practitioners Examples: PT, OT, speech language therapist, clinical pharmacists (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

Hospital IG §482.12(a)(1) – Medical Staff – Understanding CMS Requriements for Credentialing and Privileging Hospital IG §482.12(a)(1) – Medical Staff – If allowed by State law non-physician practitioners may be appointed Physician assistant Nurse practitioner; Clinical nurse specialist Certified registered nurse anesthetist Certified nurse-midwife Clinical social worker Clinical psychologist Anesthesiologist’s assistant Registered dietician or nutrition professional (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com Kathy Matzka, CPMSM, CPCS

Hospital §482.22(a)(2) MS must examine the credentials of all eligible candidates for MS membership and make recommendations to the GB on the appointment of these candidates in accordance with State law, including scope-of-practice laws, and MS bylaws, R&R A candidate who has been recommended by the MS and who has been appointed by the GB is subject to all MS bylaws, R&R, in addition to the requirements contained in this §482.22 (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

Admitting privileges – Hospital and CAH Licensed practitioners (e.g., nurse practitioners, midwives, etc.), as allowed by the State may admit patients Medicare patients under care of MD, DO, DDS, DPM, OD, DC, PhD (scope of practice as permitted by law) If a Medicare patient is admitted by a practitioner not specified, patient is under the care of a MD/DO (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

Hospital IG §482.22(a)(2) Medical Staff The individual’s credentials to be examined must include at least: A request for clinical privileges; Evidence of current licensure; Evidence of training and professional education; Documented experience; and Supporting references of competence. (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

Hospital Interpretative Guidelines §482.22(a)(2) Medical Staff Must have a separate credentials file for each individual (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

Credentials Files What goes in? Format (sections, tabs, etc.) File retention policy How long to keep What to keep Access Electronic (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

Hospital Interpretative Guidelines §482.22(a)(2) Medical Staff It cannot be assumed that every practitioner can perform every task/activity/privilege that is specified for the applicable category of practitioner. The individual practitioner’s ability to perform each task/activity/privilege must be individually assessed (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

Sample Privilege Form Language Core or Category If you do not wish to request or perform a procedure/privilege appearing on this list, please cross it off the list and initial (or write in below). List Please limit your requests to those procedure/privileges that you will be performing at this facility and which your professional liability insurance will cover.

Transference of Skill A transference of skill occurs when the same skills are utilized for different procedures If a physician has not performed a specific procedure, but has performed another procedure where those skills would transfer these can be grouped together May not apply to surgeries requiring more specialized skills or for complex surgeries not regularly performed (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

CAH § 485.639 Surgical services If CAH provides surgical services, surgical procedures must be performed in a safe manner by qualified practitioners who have been granted clinical privileges by the GB or responsible individual in accordance with the designation requirements under this section (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

Surgical Services Hospital and CAH Must specify the surgical privileges for each practitioner that performs surgical tasks MD/DO, DMD, DDS, DPM, RNFA, NP, surgical PA, surgical technicians, etc. If under supervision, the specific tasks/procedures and the degree of supervision (to include whether or not the supervising practitioner is physically present in the same OR, in line of sight of the practitioner being supervised) delineated in that practitioner’s surgical privileges and included on the surgical roster.

Definition of Surgery - ACS “Surgery is performed for the purpose of structurally altering the human body by the incision or destruction of tissues and is part of the practice of medicine. Surgery also is the diagnostic or therapeutic treatment of conditions or disease processes by any instruments causing localized alteration or transposition of live human tissue which include lasers, ultrasound, ionizing radiation, scalpels, probes, and needles…

Hospital IG §482.51(a)(4) If the hospital utilizes RNFA, surgical PA, or other non-MD/DO surgical assistants, it must establish criteria, qualifications and a credentialing process to grant specific privileges based compliance with the privileging/credentialing criteria and in accordance with Federal and State laws and regulations Includes surgical services tasks conducted by these practitioners while under the supervision of an MD/DO

CAH §485.639(a) MS bylaws include criteria for determining the privileges to be granted and procedure for applying the criteria Surgical privileges granted in accordance with the competencies of each practitioner MS appraisal procedures must evaluate each individual practitioner’s training, education, experience, and demonstrated competence as established by the CAH’S QA program, credentialing process, the practitioner’s adherence to CAH policies and procedures, and in accordance with scope of practice and other State laws and regulations (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

Hospital and CAH Surgical privileges reviewed and updated at least every 2 years Current roster and suspension/restriction list in surgical suite and wherever scheduling performed (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

Hospital IG §482.22(a)(2) Medical Staff Practitioner and appropriate hospital patient care areas/departments are informed of the privileges granted to the practitioner (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

Communicating to Stakeholders Understanding CMS Requriements for Credentialing and Privileging Communicating to Stakeholders Practitioners Hospital Staff Department chief External entities See sample policy and procedure (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com Kathy Matzka, CPMSM, CPCS - - ICAHN - April 22, 2010

Survey Procedures – Hospital and CAH Review the hospital’s method for reviewing the surgical privileges of practitioners. This method should require a written assessment of the practitioner’s training, experience, health status, and performance (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

Documenting Recommendations Understanding CMS Requriements for Credentialing and Privileging Documenting Recommendations Use of forms Documentation for minutes (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com Kathy Matzka, CPMSM, CPCS - - ICAHN - April 22, 2010

CAH §485.641(b)(4) Quality Assurance The quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy at the CAH are evaluated by-- (i) One hospital that is a member of the network, when applicable; (ii) One QIO or equivalent entity; (iii) One other appropriate and qualified entity identified in the State rural health care plan; Applies to agreements with distant-site telemedicine entity Agreements with distant- site hospitals give that hospital responsibility

§ 482.12 CoP: Governing body - 5/14 Change If a hospital is part of a hospital system consisting of multiple separately certified hospitals and the system elects to have a unified and integrated medical staff must determine that this is in accordance with all applicable State and local laws Must meet four qualifications… (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

§ 482.12 CoP: Governing body - 5/14 Change MS members holding privileges at each separately certified hospital in the system must vote by majority either to participate in a unified and integrated medical staff structure or to opt out of such a structure The unified, integrated MS must have bylaws, rules, and requirements that describe Processes for self-governance, appointment, credentialing, privileging, and oversight Peer review policies and due process rights guarantees Process for medical staff members of each separately certified hospital to be advised of their rights to opt out of the unified structure after a majority vote by the members (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

§ 482.12 CoP: Governing body - 5/14 Change The unified, integrated MS must be established in a manner that takes into account each hospital's unique circumstances, and any significant differences in patient populations served and services offered in each hospital The unified, integrated MS must give due consideration to the needs and concerns of ­members of the medical staff, regardless of practice or location, and must have mechanisms in place to ensure that issues local to particular hospitals are duly considered and addressed (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

§482.12 CoP: Governing body - 5/14 Change Consult directly with individual responsible for the organization and conduct of the hospital’s medical staff, or his or her designee At a minimum, consultation must occur periodically throughout the fiscal or calendar year and include discussion of matters related to the quality of medical care provided to patients of the hospital For a multi-hospital system with single GB, the system GB must consult directly with the individual responsible for the MS (or designee) of each hospital within its system (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

§ 482.12 CoP: Governing body “Direct consultation” means that the governing body, or a subcommittee of the governing body, meets with the leader(s) of the medical staff(s), or his/her designee(s) either face-to-face or via a telecommunications system permitting immediate, synchronous communication. Membership on the governing body by a medical staff member is not sufficient per se to satisfy the requirement for periodic consultation In such a situation the hospital meets the consultation requirement only if the medical staff member serving on the governing body is the leader of the medical staff, or his or her designee, and only if such membership includes meeting with the board periodically throughout the fiscal or calendar year and discussing matters related to the quality of medical care provided to patients of the hospital. (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

§ 482.28 CoP: Food and dietetic services 5/14 Change Patient diets, including therapeutic diets, must be ordered by one of the following: Practitioner responsible for the care of the patient Qualified dietitian or qualified nutrition professional authorized by the medical staff and in accordance with State law governing dietitians and nutrition professionals (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

§ 482.54 Condition of participation: Outpatient services (c) Standard: Orders for outpatient services. Outpatient services must be ordered by a practitioner who meets the following conditions: (1) Is responsible for the care of the patient. (2) Is licensed in the State where he or she provides care to the patient. (3) Is acting within his or her scope of practice under State law. (4) Is authorized in accordance with policies adopted by the medical staff, and approved by the governing body, to order the applicable outpatient services. This applies to the following: (i) All practitioners who are appointed to the hospital’s medical staff and who have been granted privileges to order the applicable outpatient services. (ii) All practitioners not appointed to the medical staff, but who satisfy the above criteria for authorization by the hospital for ordering the applicable outpatient services for their patients. (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

Statement of Deficiencies (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

Hospital Deficiency Data http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Hospitals.html Downloads section at bottom of page Full Text Statements of Deficiencies Hospital Surveys - Updated 1/15/2015 [ZIP, 14MB] (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

Hospital Deficiency Data http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Hospitals.html

Questions ? Comments ! (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

Medicare advantage (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

Medicare Managed Care – Medicare Advantage Title 42 ,Chapter IV, Subchapter B, Part 422 - Medicare Advantage Program Subpart E—Relationships With Providers http://www.ecfr.gov/cgi-bin/text-idx?SID=377e08c0984dd4046da0ab7f59667bcb&node=sp42.3.422.e&rgn=div6 Medicare Managed Care Manual Chapter 6 - Relationships With Providers http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS019326.html Rev. 82, 04-27-07 Proposed Change in FR February 12, 2015 – None for credentialing

Medicare Managed CarePage http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS019326.html

MAO – 42 Code of Federal Regulations 422 MAO – 42 Code of Federal Regulations 422.204 - Provider selection and credentialing 42 Code of Federal Regulations 422.204 - Provider selection and credentialing – spells out basics MA organization has written policies and procedures for selection and evaluation of providers Policies must conform with the credential and recredentialing requirements set forth in paragraph (b) of this section and with the antidiscrimination provisions set forth in § 422.205 MA organization must follow documented process with respect to providers and suppliers who have signed contracts or participation agreements Differs For providers (other than physicians and other HC professionals) For physicians and other HC professionals, including members of physician groups Medicare Managed Care Manual Chapter 6 has specifics (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

MAO – 60.3 - Credentialing, Monitoring, and Recredentialing Credentialing is required for: All physicians who provide services to the MAO’s enrollees, including members of physician groups All other types of HC professionals who provide services to the MAO’s enrollees and who are permitted to practice independently under state law (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

MAO – 60.3 - Credentialing, Monitoring, and Recredentialing Credentialing is not required for: HC professionals who are permitted to furnish services only under the direct supervision of another practitioner Hospital-based HC professionals who provide services to enrollees incident to hospital services, unless those health care professionals are separately identified in enrollee literature as available to enrollees Students, residents, or fellows (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

MAO – 20.2 - Consultation in Development of Credentialing Policies Credentialing and recredentialing standards for types of providers and for specialists reviewed by clinical peers, through establishment of a credentialing committee or other mechanism Process for peer review when the MAO is considering employing or contracting with a provider who does not meet its established credentialing standards (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

MAO – 60.1 - Notice of Reason for Not Granting Participation MAO which declines to include a given provider or group of providers in its network, it must furnish written notice to the affected provider(s) on the reason for the decision (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

MAO - Initial Credentialing Written application Verification of information from primary and secondary sources Confirmation of eligibility for payment under Medicare Site visits as appropriate A limited set of procedures for newly trained health care professionals permits initial credentialing for a period of up to 60 days (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

MAO – Written Application Completed application Signed/dated attestation of correctness and completeness Information no more than six months old on the date on which the health care professional is determined (for example, by a credentialing committee) to be eligible for appointment or contract All items verified prior to the appointment (exception: pending DEA) (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

MAO – Work History Includes relevant work applicable to the position being sought Need at least 5 years work history and a statement regarding: Any limitations in ability to perform the functions of the position, with or without accommodation History of loss of license and/or felony convictions History of loss or limitation of privileges or disciplinary activity (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

MAO – Primary Source Verification Required A current valid license to practice: Verification that the license was in effect at the time of the credentialing decision Education and training - professional school and completion of a residency or specialty training, if applicable Board certification in each clinical specialty area for which the HC professional is credentialed Verification is required only for the highest level of education or training attained Verification of board certification is highest level provided that board does PSV of education and training (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

Primary Source Verification is Not Always Required Secondary sources of information for these requirements are widely accepted & appropriate The sources of and methods for obtaining the designated credentialing requirements listed are suggested appropriate sources methods - not intended as an all-inclusive listing of sources/methods that an MA organization may employ to acquire the requisite information Secondary source will be considered acceptable provided that the secondary source verifies the information from the originator (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

MAO – Clinical privileges in good standing Clinical privileges in good standing at the hospital designated as the primary admitting facility if applicant has admitting privileges Information obtained on application that lists the current status and type of admitting privileges is acceptable Information may be obtained by contacting the facility obtaining a copy of the practitioner directory attestation by the health care professional (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

MAO – Malpractice Insurance Current, adequate malpractice insurance meeting the MAO’s requirements Obtained via one of the following: malpractice carrier copy of the insurance face sheet attestation by the health care professional (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

MAO – DEA or CDS In effect at the time of the credentialing decision If pending, may credential if a process under which other DEA-certified contracted practitioners write all prescriptions that require a DEA number is adopted and implemented Process includes verification of the newly issued DEA certificate Verification with Agency issuing CDS National Technical Information Service (NTIS) database Obtaining a copy of the certificate If applicant states that he/she does not prescribe, this requirement is not applicable (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

MAO – Claims/NPDB/Sanctions/ Eligibility A history of professional liability claims resulting in settlements or judgments paid by or on behalf of the health care professional can be obtained from the malpractice carrier or NPDB For physicians NPDB Information about sanctions or limitations on licensure from the applicable state licensing agency or board, or from a group such as FSMB Eligibility for participation in Medicare (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

MAO – 60.2 - Confirmation of Eligibility for Participation in Medicare Excluded and Opt-Out Provider Checks Office of the Inspector General (OIG) sanction list Opt-out of Medicare info obtained from the local Medicare Part B carrier - must check this list “on a regular basis” (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

MAO – Site Visits CMS does not require MAOs to conduct initial credentialing or recredentialing site visits Must establish a policy for conducting site visits Frequency of site visits Procedures for detecting deficiencies/mechanisms to address deficiencies Should “consider” requiring initial credentialing site visits of the offices of primary care practitioners, obstetrician-gynecologists, or other high-volume providers, as defined by the MA organization Visit should include an evaluation of the site’s accessibility, appearance, and adequacy of equipment, medical record keeping practices and the confidentiality requirements (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

MAO – Initial Requirements for a Newly Trained HC Professional Completed all appropriate training and education within the last 12 months Have a policy that permits initial credentialing for a period of up to 60 days with verification of current, valid license from primary sources; malpractice settlements from the last 5 years by verifying with the malpractice carrier or NPDB (attestation not accepted) P&P which ensures that the practitioner meets all standard credentialing requirements after 60 days Credentialing Committee reviews and makes final determination about granting such an initial 60-day credentialing period (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

MAO – Ongoing Monitoring Develop and implement policies that address the ongoing monitoring of sanctions and grievances filed against health care professionals Ongoing monitoring of: Lists of practitioners who have been sanctioned Opt-out list Beneficiary grievances Sanctions and limitations on licensure on a regular basis between recredentialing cycles MAO is required to ensure that all credentialing requirements are current at the time of initial credentialing and/or recredentialing, but is not required to monitor and account for any expiration dates on a continuous basis unless required to do so by the state (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

MAO – Recredentialing Process At least every 3 years Updates information obtained in initial credentialing Includes an attestation of the correctness and completeness of new information Considers performance indicators such as those collected through QAPI program Utilization management system Grievance system Enrollee satisfaction surveys Other activities of the MAO (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

MAO – Recredentialing Process Licensure must be re-verified from primary sources Board certification must be re-verified only if the provider was due to be recertified or states that he/she has become board certified since the last time he/she was credentialed or recredentialed National Practitioner Data Bank Sanction or restriction information from licensing agencies and Medicare (OIG/Opt-out) Admitting privileges (attestation ok) Malpractice coverage (carrier/face sheet/attestation) DEA/CDS certificate (NTIS/CDS agency/copy (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

Questions ? Comments ! (c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com