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Understanding CMS Requriements for Credentialing and Privileging
• 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
• 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
• 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
• 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
• 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.
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Understanding CMS Requriements for Credentialing and Privileging
• “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…
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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
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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
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
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Understanding CMS Requriements for Credentialing and Privileging
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
• 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
• 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
• “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.
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.
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
– 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
• 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
• 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)
• 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
• 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
• 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
• 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
• 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)