1. Understanding CMS Requriements for Credentialing and Privileging
4/21/ :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)
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Kathy Matzka, CPMSM, CPCS 1

2. Understanding CMS Requriements for Credentialing and Privileging
CMS Hospital CoPs
All Interpretative guidelines and manuals are on website
Rev. 137, (most recent hospital)
Rev. 110, – most recent CAH
Most recent rule changes for MS posted in Federal Register May 12, 2014
Kathy Matzka, CPMSM, CPCS

3. CMS Hospital Page

4. Surveyor & Certification Memos

5. 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

6. 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

7. 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 § (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

8. 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

9. 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

10. 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

11. 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
Kathy Matzka, CPMSM, CPCS

12. 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

13. 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

14. 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

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

16. 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

17. 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

18. 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.

19. 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

20. 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

21. 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.

22. 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…

23. 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

24. CAH § (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

25. 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

26. 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

27. 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
Kathy Matzka, CPMSM, CPCS - - ICAHN - April 22, 2010

28. 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

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

30. 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

31. § 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

32. § 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

33. § 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

34. §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

35. § 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

36. § 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

37. § 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

38. Statement of Deficiencies
(c) Kathy Matzka, CPMSM, CPCS

39. Hospital Deficiency Data
Downloads section at bottom of page
Full Text Statements of Deficiencies Hospital Surveys - Updated 1/15/2015 [ZIP, 14MB]
(c) Kathy Matzka, CPMSM, CPCS

40. Hospital Deficiency Data

41. Questions ?
Comments !
(c) Kathy Matzka, CPMSM, CPCS

42. Medicare advantage
(c) Kathy Matzka, CPMSM, CPCS

43. Medicare Managed Care – Medicare Advantage
Title 42 ,Chapter IV, Subchapter B, Part Medicare Advantage Program Subpart E—Relationships With Providers
Medicare Managed Care Manual Chapter 6 - Relationships With Providers
Rev. 82,
Proposed Change in FR February 12, 2015 – None for credentialing

44. Medicare Managed CarePage

45. MAO – 42 Code of Federal Regulations 422
MAO – 42 Code of Federal Regulations Provider selection and credentialing
42 Code of Federal Regulations 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 §
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

46. 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

47. 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

48. 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

49. 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

50. 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

51. 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

52. 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

53. 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

54. 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

55. 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

56. 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

57. 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

58. 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

59. 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

60. 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

61. 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

62. 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

63. 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

64. 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

65. Questions ?
Comments !
(c) Kathy Matzka, CPMSM, CPCS