Credentialing. Contents Delegated Credentialing-Credentialing in CVO Credentialing in Payor...
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Transcript of Credentialing. Contents Delegated Credentialing-Credentialing in CVO Credentialing in Payor...
Credentialing
Contents
Delegated Credentialing-Credentialing in CVO
Credentialing in Payor Organizations
Credentialing in Provider Organization
Accreditation
Overview of Credentialing
Generic Credentialing Process
My Credentialing Model
Certifications on credentialing
Potential Business Areas
OVERVIEW OF CREDENTIALING
Credentialing/ Privileging
Select Competent provider
Assessing qualification
Verifying
Obtaining Information
Credentialing
• 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
PSV and Ongoing Monitoring
Primary Source VerificationIt 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 MonitoringProvider who are admitted into the organization are subjected to on goingmonitoring 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
Why Credentialing?
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.
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
Driving Force
Quality
AccreditationStandards &
requirements
Case Laws
Regulatory Requirements
Risk Management
Customer & Payor
Expectations
Evolution of credentialing
1900’s
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
Who is credentialed?
Participation
Membership
Affiliation
CertificationPrivileges
Credentialing Happens During
Healthcare Organizations
IndividualProviders
Who is Credentialed?
E.g.: Doctor , Nurse, Dentist… etc
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
VERIFICATION AND INFO GATHERING
Credentials file is developed as data and info are
collected
ANALYSISReview and evaluation of
information in file
DECISIONAnd notification to applicant
Monitoring and
evaluation
All or part of verification may be
outsourced or delegated
Recredentialing every two years
Elements which are verified
Elements Website ImageMail/Fax/E-
mail Phone callElectronic
Query
DEA - - -CDS - - -PLI - - - -
State License - -Board - -
Education - - -Work History - - -
Hospital Affiliations - -Medicare/Medicaid Opt out - - - -
OIG - - - -GSA - - - NPDB - - - - HIPDB - - - - FSMB - - - -
OIG and GSA
GSAThe 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.
OIGThe 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
NPDB and HIPDB
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
againsthealthcare 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.
National Practitioner Data Bank(NPDB)
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.
ACCREDITATION
Accreditation
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
•Hospitals•IPA
•CVO
•HMO•PPO•POS
CVO
Payor Organizations
Provider Organizations
CREDENTIALING IN PROVIDER ORGANIZATIONS
HOSPITAL CREDENTIALING
• Hospitals• IPA
• CVO
• HMO• PPO• POS
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
REQUEST FOR
APPLICANTION
IS APPLICATION COMPLETE ?
APPLICATION SENT TO APPLICANT
INFO RECEIVED FROM APPLICANT
APPLICATION STILL TREATED
INCOMPLETE.APPLICANT NOTIFIED
FURTHER INFO REQUESTED
APPLICATION RECEIVED
MSO VERIFIES THE INFO
Yes
NO
APPLICATION REVIEWED
DEPARTMENT CHAIR MAKES WRITTEN REPORT AND
RECOMMENDATION FOR DELINIATION
APPLICATION SENT TO AND RECIVED BY CREDENTIALS
COMMITTEE
CREDENTIALS COMMITTEE REOMMENDS:A. APPROVED WITH NO ESTRICTIONSB. APPROVED WITH QUALIFICATIONS OR CONDITIONSC. DENIAL
INFORMATION SENT TO AND REVIEWEDBY EXECUTIVE COMMITEE
EXECUTIVE COMITTE RECOMMENDSA. APPROVAL WITH NO RESTRICTIONSB. APPROVAL WITH QUALIFICATION OR CONDITIONSC. DENIAL OF ALL OR PART OF APPLICATION
IS THERE ANY DENIAL
RECOMMENDED?
APPLICANT NOTIFIED INCLUDING RIGHT TO
HEARING
HEARING RIGHTS
EXERCISED?
GOVERNING BODY MAKES
DECISION. APPLICANT NOTIFIED
Yes
SENT TO GOVERNING BODY FOR FINAL ACTION
NO
APPLICANT NOTIFIED
DUE PROCESS HEARING HELD
NO
EXECUTIVE COMMITTEE AND APPLICAT NOTIFIED
OF RESULTS
APPELLATE REVIEW
REQUEST?
APPELLATE REVIEW HELD BEFORE GOVERNING BODY
Yes
FINAL DECISION
MADE PARTIES NOTIFIED
NO FURTHER ACTION
REQUIRED
NO
NO
Yes
Credentialing in Hospital
Yes
CREDENTIALING IN PAYOR ORGANIZATIONS
MCO CREDENTIALING
• Hospitals• IPA
• CVO
• HMO• PPO• POS
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
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
In-House Credentialing
• Quality Management
Function
• Provider Relations
Rep
• In-house credentialing
Dept
Credentialing In MCO
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
5
Collect and
verify
provider’s
credentials
6Analysis and
decision
7
Recredential
-ing
4
Identification
of potential
Providers
8
Maintenanc
e and
problem
resolution
Credentialing Process in MCO
Delegation of credentialing Process to another
Organization for Specified Practitioners and /or
Providers
Preapplication Application
Verification
Information Gathering
Office Evaluation
Medical Record Review
Delegation of Verification to a
CVO
File development
Review and Approval or decline
to credential
Rrecedential
Structure of Credentialing Process
Data Collection and File Maintenance
Review and Recommendation
Approval ( May be delegated to credentials Committee/
Administration/ Medical director by governing Board)
Contract or Letter of Agreement After Initial
Credentials Approval
Activity Accountability
Credentialing Staff
Credentialing Committee or Review Body
Medical Director
Governing Board
Provider Relations / Contracting
Office evaluation & Medical Record Review
Office Evaluation
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 credentialedScopeBylaws Versus ContractsAccrediting Organizations and standardsAppointmentPrivilegingPhysician Office Site visits and Medical
Record Review
DELEGATED CREDENTIALING -CREDENTIALING IN CVO
DELEGATED CREDENTIALINGCVO CREDENTIALING
• Hospitals• IPA
• CVO
• HMO• PPO• POS
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 CommitteeQuality Management CommitteeUtilization Management Committee
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 MCOHospitals and Other facilitiesProvider OrganizationsCredential Verification Organization
Potential Delegates of a HospitalCredential Verification OrganizationPractice management organizations
CVO
CVO: Credential Verification OrganizationThey link providers to hospitals and managed care
organizationsThey 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
MCO sends request for credentialing / recredentialing
CVO Send’s app to provider
Is Application
received
Is Application Complete
Verify the provider’s credentials
Send a report on the provider to the MCO
• 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
Credentialing process in a CVO
NO
Yes
NO
Yes
ADDITIONAL INFO ON CREDENTIALING
DISASTER CREDENTIALINGCENTRALIZED APPROCH TO CREDENTIALINGINFORMATION 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 costEfficient credentialing
Examples for centralized credentialing approach
CAQHABMSOneSourceFederal Credentialing
Program (FCP)
Information Technology Boosts Credentialing
Helps Streamline otherwise tedious credentialing
Verification of credentials made onlineOnline ApplicationsSoftware to generate same provider’s info into
organization specific applicationMaintaining of massive amount of information
storageSpeedy access of informationHelps reduce Turnaround timePaperless credentialing reduces
Administrative cost
CERTIFICATIONS
CERTIFICATION TO BECOME A PROFESSIONAL CREDENTIALER
Certification on Credentialing
(CPCS) Certified ProviderCredentialing 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
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
CPCSCPMSM
POTENTIAL BUSINESS
POTENTIAL BUSINESS AREASTOP CVOsTOP 10 MCOs
Potential Business Areas
COGNIZANTCOGNIZANT
Potential Business
CVO MCOAmbulatory
Care OrgIPA /
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
Top 10 Publicly Traded MCO’s in US
Company Revenue
Total Enrollment
United Health Group $20.2 Billion 30.3 MillionWell Point Inc $15.3 Billion 35.3 MillionAetna Inc $7.8 Billion 17.7 MillionHumana Inc $7.1 Billion 8.4 MillionCIGNA Corporation $4.1 Billion 11.9 MillionHealth Net Inc $3.8 Billion 6.7 MillionCoventry Health Care Inc $3.0 Billion 3.7 MillionAmeri Group Corp $1.1 Billion 1.7 MillionCentene Corp $897.1
Million1.2 Million
Molina Health Care Inc $791.6 Million
1.2 Million
List of Health Insurance Co
MY CREDENTIALING MODEL
My Credentialing Model
CVO
CAQHHospitals
MCO
GSA
OIG
Providers
HIPDB
NPDB
Buy verified info
Get excluded list every Month
Query
Buy Verified info
Fill a
pp
Reatte
st a
pp
(120
day
s)
Provider app is downloaded
Send Hospital
Roster
Help CVO in verifying credentials.Authorize to release the info
Questions