Credentialing Article

Question 1

Credentialing

Answer 1

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.

Question 2

3 parameters of credentialing

Answer 2

Current licensure
Education and relevant training
Experience, ability and current competency

Question 3

Verify at original source of the specific credential if possible

Question 4

NPDB

Answer 4

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

Question 5

Quality of care and patient safety

Answer 5

Linked to credentialing
Now in the scope of compliance programs

Question 6

Medicare’s conditions of participation (CoP)

Answer 6

Basis of evaluation for organizations that treat Medicare and Medicaid patients

Question 7

The Healthcare Quality Improvement Act of 1988

Answer 7

Provided immunity for peer review and established the NPDB

Question 8

LIP provide care without supervision within the scope of their license

Question 9

Independent practitioners

Answer 9

MD, DO, DDS, DMD, DPMS

Question 10

Privileges determined by

Answer 10

Accreditation requirements
Eligibility
Internal processes-bylaws, policies
External sources-state and federal law

Question 11

Clinical privilege process

Answer 11

Defined and explained in the medical staff bylaws

Question 12

Privileging

Answer 12

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

Question 13

Process by hospital

Answer 13

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

Question 14

Medical staff bylaws

Answer 14

Will accomplish the tasks of credentialing
Privileging
Reappointment
Peer review
Organization is self-governing
Approved by hospital board

Question 15

Graduate education programs

Answer 15

The joint commission requires the organized medical staff to have a defined process for supervision by an LIP

Question 16

Teaching hospital billing

Answer 16

Medicare notes that these services must be provided and billed by a physician who is qualified to do so.

Question 17

Qualified surgeon

Answer 17

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

Question 18

False Claims Act

Answer 18

Any claims submitted to Medicare by noncredentialed physicians are at risk

Question 19

Medicare’s ‘incident to’ billing

Answer 19

Allows physicians to bill for services provided by ancillary staff
Billed as though performed by physician

Question 20

NNP

Answer 20

Non-physician practitioner

Question 21

The Joint Commission is the central force in the external review of hospital quality

Question 22

Medicare as the oversight body for the Joint Commission

Question 23

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