Credentialing Article Flashcards
Credentialing
The process of obtaining , verifying and assessing the qualifications of a licensed independent practitioner (LIP) to determine whether he or she is qualified to provide patient care services in and for a healthcare organization.
3 parameters of credentialing
Current licensure
Education and relevant training
Experience, ability and current competency
Verify at original source of the specific credential if possible
NPDB
National Practitioner Data Bank
National information clearinghouse that collects and releases certain information related to the professional competence and conduct
Information on medical malpractice and adverse actions
Limitation in privileges for longer than 30 days
Quality of care and patient safety
Linked to credentialing
Now in the scope of compliance programs
Medicare’s conditions of participation (CoP)
Basis of evaluation for organizations that treat Medicare and Medicaid patients
The Healthcare Quality Improvement Act of 1988
Provided immunity for peer review and established the NPDB
LIP provide care without supervision within the scope of their license
Independent practitioners
MD, DO, DDS, DMD, DPMS
Privileges determined by
Accreditation requirements
Eligibility
Internal processes-bylaws, policies
External sources-state and federal law
Clinical privilege process
Defined and explained in the medical staff bylaws
Privileging
Process whereby a specific scope and content of patient care are authorized for a healthcare practitioner by à healthcare organization, based on evaluation of the individual’s credentials and performance
Objective, evidence-based process
Process by hospital
Determine whether there is sufficient clinical performance information to make a decision
Ensure that the application is acted upon in a timely fashion according to the medical staff bylaws
Ensure that practitioner information is kept updated
Medical staff bylaws
Will accomplish the tasks of credentialing
Privileging
Reappointment
Peer review
Organization is self-governing
Approved by hospital board
Graduate education programs
The joint commission requires the organized medical staff to have a defined process for supervision by an LIP
Teaching hospital billing
Medicare notes that these services must be provided and billed by a physician who is qualified to do so.
Qualified surgeon
Defined by the joint commission as an individual or staff member who is authorized to provide care, treatment and services by virtue of education, training, experience, etc
False Claims Act
Any claims submitted to Medicare by noncredentialed physicians are at risk
Medicare’s ‘incident to’ billing
Allows physicians to bill for services provided by ancillary staff
Billed as though performed by physician
NNP
Non-physician practitioner
The Joint Commission is the central force in the external review of hospital quality
Medicare as the oversight body for the Joint Commission
Important for a compliance program to have an established and working linkage with its medical staff leadership to ensure compliance with medical staff activities that may affect a compliance program’s overall effectiveness
