Overcoming the challenges of credentialing and privileging
- 1. 5/18/2020 1 OVERCOMING THE CHALLENGES OF CREDENTIALING AND PRIVILEGING Michelle Layton BSN, MBA Infidium Healthcare Solutions, LLC michellel@infidiumhs.com Disclaimers This presentation is not endorsed by Management Strategists Consulting Group (MSCG). This presentation is not endorsed by Health Resources Services Administration (HRSA) or the Bureau of Primary Health Care (BPHC). Not employed by MSCG or BPHC. Independent Consultant who is contracted to conduct Operational SiteVisits (OSV), provideTechnical Assistance and assist health centers prepare for their OSV. Confidentiality Notice: This document is confidential and contains proprietary information and intellectual property of Infidium Healthcare Solutions, LLC. Neither this document nor any of the information contained herein may be reproduced or disclosed under any circumstances without the express written permission of Infidium Healthcare Solutions, LLC. Agenda Back to Basics ◦ Differences between Credentialing and Privileging Compliance Manual Changes How Credentialing and Privileging relates to Scope of Project Peer Review Credentialing and Privileging During COVID-19 Updates/Question and Answer Session
- 2. 5/18/2020 2 Back to Basics Back to Basics Credentialing and privileging… Oh… I thought they were the same thing? Definitions Credentialing The process of assessing and confirming the qualifications of a licensed or certified health care practitioner Privileging/Competency The process of authorizing a licensed or certified health practitioner’s specific scope and content of patient care services
- 3. 5/18/2020 3 Definitions Licensed Independent Practitioner (LIP) Physician, Dentist, Nurse Practitioner and Nurse Midwife or “ any other individual permitted by law and the organization to provide care and services without supervision, within the scope of the individual’s license and consistent with individually granted clinical privileges Definitions Other Licensed or Certified Health Care Practitioner (OLCP) An individual who is licensed, registered or certified but is not permitted by law to provide patient care services without direction or supervision. Examples include: • Laboratory Technicians • Medical Assistants • Registered Nurses • Dental Hygienists Definitions Other Clinical Staff A clinical staff member that performs services in a state, territory or other jurisdiction that does not require licensure or certification. Examples include: • Medical Assistants • Dental Assistants • Community Health Workers
- 4. 5/18/2020 4 Definitions Primary Source Verification Verification by the original source of a specific credential to determine the accuracy of a qualification reported by an individual health care practitioner. Examples include: • Internet verification (i.e., state database) • Direct correspondence • Reports from Credentials Verification Organization Definitions Primary Source Verification Possible sources for PSV of verification of education and residency for physicians include: • American Medical Association (AMA) Masterfile • American Board of Medical Specialties • American Osteopathic Association Physician Profiles • Education Commission for Foreign Medical Graduates (ECFMG) – International graduates licensed after 1986 Definitions Primary Source Verification Possible sources for PSV of verification of certifications for other LIPs (i.e., PA, NP, etc.) include: • American Nurses Credentialing Center • American Midwifery Certifying Board • National Commission on Certification of Physician Assistants
- 5. 5/18/2020 5 Definitions Secondary Source Verification Methods of verifying a credential that are not considered an acceptable form of primary source verification. Examples include: • Notarized copy of the credential • Copy of the credential that is made from an original by approved staff Definitions Reappointment The process of verifying expired credentials and re- privileging of a licensed or certified health care practitioner on a recurring basis Credentialing and Privileging Activities Credentialing and Recredentialing activities for LIPs include: • Verification of identity – Initial only • Verification of current licensure, registration or certification – Primary source • Verification of education and training – Primary source, initial only • National Practitioner Data Bank Query • Verification of DEA Registration • Verification of basic life support training
- 6. 5/18/2020 6 Credentialing and Privileging Activities Credentialing and Recredentialing activities for OLCPs include: • Verification of identity – Initial only • Verification of current licensure, registration or certification – Primary source • Verification of education and training – Primary or Secondary Source, initial only • National Practitioner Data Bank Query • Verification of DEA Registration (if applicable) • Verification of basic life support training Credentialing and Privileging Activities Privileging and Reprivileging activities for LIPs include: • Verification of fitness for duty • Verification of immunization and communicable disease status • Verification of current clinical competence • Initial – Verification via training, education, reference reviews • Renewal – Verification via peer review, performance improvement activities Credentialing and Privileging Activities Privileging and Reprivileging activities for OLCPs include: • Verification of fitness for duty • Verification of immunization and communicable disease status • Verification of current clinical competence • Based on Supervisory evaluation of clinical competence per the job description
- 7. 5/18/2020 7 Temporary Privileges • Privileges SHOULD: • Be granted in accordance with FTCA Guidelines • Be approved by the CEO upon the recommendation of appropriate department head • Privileges SHOULD NOT: • Exceed more than 90 days • Be renewed • Be granted in lieu of expired credentials Credentialing and Privileging Activities Initial Privileging and Reappointment Privileging is completed after the health center has verified all necessary credentials for a practitioner Re-appointment is completed on a recurring basis (i.e., every two years), as determined by the health center Re-appointment involves the verification of expired credentials and re-privileging of practitioners The health center determines who has approval authority for Credentialing and Privileging Credentialing and Privileging Activities Delineation of Privileges (Clinical Services) • Subsequent to credentials verification, the practitioner submits a request for clinical privileges, which includes completion of a Delineation of Clinical Services Form. • The Delineation of Clinical Services Form: • Includes only services and sites listed in the health center’s approved scope of project • Is specific to each specialty within the health center (i.e., Dental, Behavioral Health, Family Practice, Obstetrics) • Outlines Requested Services, Non-Requested Services, Approved Services and Non-Approved Services
- 8. 5/18/2020 8 Compliance Manual Changes Compliance Manual Changes The Compliance Manual supersedes the following Policy Information Notices: ◦ 2001-16: Credentialing and Privileging of Health Care Practitioners ◦ 2002-22: Clarification of BPHC Credentialing and Privileging Policy Outlined in PIN 2001-16 Do NOT include any references to the above PINs in the Credentialing and Privileging Policy Ensure the Credentialing and Privileging Policy demonstrates a clear understanding of the difference between credentialing and privileging, as well as the associated activities Ensure the Credentialing and Privileging Policy is reflective of current practice ◦ Board approval or not, reference to CVO Compliance Manual Changes The Credentialing and Privileging Policy does NOT require board approval Credentialing and Privileging of clinical staff does NOT require board approval The health center must have documented procedures in place to ensure competency of Other Clinical Staff ◦ The health center determines what aspects of the credentialing and privileging process apply ◦ None required if the health center does not utilize Other Clinical Staff The health center determines the timeframe for recurring credentialing and renewal of privileges ◦ Exercise caution!! Certain credentials have specific recurring timeframes
- 9. 5/18/2020 9 Compliance Manual Changes The health center must ensure contracted and referral providers are appropriately credentialed and privileged ◦ Contracts/referral arrangements must include provisions to support credentialing and privileging of contracted/referral providers ◦ Review of the contracted organization’s credentialing and privileging process Reappointment of Licensed Independent Practitioners requires the consider of Peer Review results or performance improvement activities There MUST be a process in place for denial, modification or revocation of privileges based on performance. Reference it in your policy!!! Compliance Manual Changes As a reminder…….. The Compliance Manual is the minimum standard for credentialing and privileging of clinical staff FederalTort Claims Act (FTCA) regulations are the highest standard for credentialing and privileging of clinical staff Utilize the HRSA Credentialing and Privileging File Review Resource (updated 2/2020) as a guideline for primary and secondary source verification Categorization of providers as LIPs and OLCPs may vary from state to state based on the specific licensure and certification requirements and scope of practice prescribed by the state Scope of Project
- 10. 5/18/2020 10 What is Scope of Project? A health center’s scope of project defines the activities supported by the Health Center Program project budget. Specifically, scope of project defines the approved service sites, services, providers, service area(s) and target population(s). https://bphc.hrsa.gov/programrequirements/scope.html What is Scope of Project? Form 5A defines the service being provided, as well as the method of service delivery. Form 5B identifies the sites where the services on Form 5A are being provided. Form 5C identifies other activities the health center may be conducting such as hospital admitting and health fairs.
- 11. 5/18/2020 11 Why is Scope of Project Important? Scope demonstrates the health center’s commitment to HRSA Scope is reflective of the operations of the health center Scope must be accurate for purposes of: ◦ Medicare/Medicaid FQHC Reimbursement ◦ FTCA Coverage ◦ 340B Drug Pricing Program Benefits
- 12. 5/18/2020 12 Why is Scope of Project Important? The health center’s Scope of Services MUST be accurate to reduce the risk associated with FTCA malpractice claims Credentialing and privileging is required to ensure appropriate FTCA coverage Services provided by FTCA covered individuals must be within the approved Scope of Project and outlined on a “Delineation of Privileges” form In the event of a malpractice claim, FTCA will do a review of the health center’s Scope of Services to determine the accuracy Health center’s that have an outstanding condition in the areas of Credentialing and Privileging or Quality Improvement/Assurance are at risk for denial of FTCA deeming status Peer Review Peer Review – Basic Concepts Peer Review must be completed: On a “routine and regular basis” ◦ Considered a quarterly QI Assessment per the Site Visit Protocol Between providers within the same specialty who are similarly credentialed In all clinical areas within the health center’s scope of project (Family Medicine, Obstetrics, Dental, Behavioral Health) Using an industry standard tool that clearly evaluates the quality of services provided and does not only perform administrative review Using a blinded methodology that ensures confidentiality of patient information
- 13. 5/18/2020 13 Peer Review – Basic Concepts The results of Peer Review must be part of the health center’s Quality Improvement Program and incorporated into the LIP reappointment process, which is evidenced by documentation in: • Credentialing and Privileging Policy • Peer Review Policy • Quality Improvement Plan • Credentialing and Privileging files Credentialing and Privileging During COVID-19 Compliance During COVID-19 Health centers are still expected to maintain compliance with HRSA’s Credentialing and Privileging Requirements, as well as FTCA Requirements HRSA recognizes the impact of COVID-19 may impact a health center’s ability to demonstrate compliance within the specific time frame or specific manner as outlined by the Compliance Manual ◦ Basic Life Support Training ◦ Patient Satisfaction Survey HRSA will consider the impact of COVID-19 on the ability of health centers to maintain compliance when making future compliance determinations ◦ The level and/or areas of leniency have not yet been determined Updated 3/30/20 – Program Oversight and Monitoring https://bphc.hrsa.gov/emergency-response/coronavirus-frequently-asked- questions.html#faqs
- 14. 5/18/2020 14 Compliance During COVID-19 Compliance with FederalTort Claims Act Requirements Temporary Privileges ◦ Utilize Program Assistance Letter (PAL) 2017-07: Temporary Privileging of Clinical Providers by FTCA Deemed Health Centers in Response to Certain Declared Emergency Situations https://bphc.hrsa.gov/sites/default/files/bphc/ftca/pdf/pal-2017-07.pdf Temporary Service Sites ◦ Utilize PAL 2020-05: Requesting a Change in Scope to AddTemporary Service Sites in Response to Emergency Events https://bphc.hrsa.gov/sites/default/files/bphc/programrequirements/pdf/pal202 005.pdf Updates Updates Deadline for submission of 2021 FTCA Health Center Deeming Applications for health center and volunteer health professionals – Extended to Monday, 7/13/20 at 11:59pm ◦ PAL 2020-02 ◦ PAL 2020-03 NPDB Query fees are waived ◦ Includes one time and continuous query ◦ Retroactive from March 1, 2020 – May 31, 2020 ◦ Credit will be given for those queries conducted on or after March 1 and prior to implementation of the waiver
- 15. 5/18/2020 15 Updates Project periods for most health centers scheduled to complete a SAC in FY2021 have been extended. Those with a current 2- or 3-year project period ending in FY2021 will: ◦ Receive a 12-month extension with funds ◦ Complete a BPR instead of a SAC ◦ Health centers in a one-year project period will still complete SAC Release of FY2021 SACs, BPRs, LAL Renewal Designation and Annual Certifications has been delayed ◦ Projected Release June 2020 Additional Resources Additional Resources • Compliatric https://www.compliatric.com/ • Health Resources and Services Administration https://www.hrsa.gov/coronavirus https://bphc.hrsa.gov/emergency-response/coronavirus- frequently-asked-questions.html#faqs https://bphc.hrsa.gov/programrequirements/scope.html https://bphc.hrsa.gov/sites/default/files/bphc/programrequirem ents/pdf/c_and_p_file_review_resource.pdf
- 16. 5/18/2020 16 Additional Resources • National Practitioner Data Bank https://www.npdb.hrsa.gov/coronavirus.jsp • FTCA https://bphc.hrsa.gov/sites/default/files/bphc/ftca/pdf/pal-2017- 07.pdf https://bphc.hrsa.gov/sites/default/files/bphc/ftca/pdf/pal-2020- 02.pdf https://bphc.hrsa.gov/sites/default/files/bphc/ftca/pdf/pal-2020- 03.pdf Questions & Answers Michelle Layton BSN, MBA Infidium Healthcare Solutions, LLC michellel@infidiumhs.com