Licensure/Licensure Sanctions

Question 1

The Joint Commission (TJC)
Licensure/Licensure Sanctions

Answer 1

Licensure is verified with the primary source at the time of appointment and initial granting of privileges; at reappointment, renewal, or revision of clinical privileges, and on expiration

Before recommending privileges, the medical staff evaluates challenges to or voluntary/involuntary relinquishment of any license or registration.

FSMB is recognized as a designated equivalent source for information regarding licensure actions.

Question 2

NCQA
Licensure/Licensure Sanctions

Answer 2

• Must confirm that the practitioner holds a valid, current license, in effect at the time of the credentialing committee’s decision.
• Only required to verify license/s in the state/s where the practitioner provides care for organization members.
• Verification must be obtained directly from the state licensing agency or its website.
• NPDB and Continuous Query can be used to verify sanctions
• The organization must verify the most recent 5 - year period available for sanctions or limitations on any state licensure held (pat and present) using one of the following:
  Physicians
• appropriate state agencies
• FSMB
• NPDB (Continuous query)
  Chiropractors
• Federation of Chiropractic
• Licensing board’s chiropractic
• State board of chiropractic examiners
  Oral Surgeons
• NPDB (continuous query)
• state board of dental examiners
  Podiatrists
• federation of podiatric medical boards
• state board of podiatric examiners
• NPDB (continuous query)
  Non_physician behavioral healthcare professionals
• appropriate state agency
• state licensure or certification board
• NPDB (continuous query)
  Time Limit: must be verified within 180 days (MCO)/120 days (CVO) of the credentialing decision
  On initial credentialing, practitioners attest to any loss of licensure since the initial licensure was granted. On re-credentialing, practitioners attest to loss of licensure since the last credentialing cycle
  Organizations are responsible for the ongoing monitoring of sanctions or limitations on licensure between re-credentialing cycles
  Information must be reviewed within 30 days of release by the reporting entity.
  If reports are not published on a regular basis, organizations must query the source at least every 6 months.
  If reports are not published, the organization must query the source within 12-18 months from the last credentialing cycle

Question 3

ACHC (HFAP) Acute Care Hospitals
Licensure/Licensure Sanctions

Answer 3

Verification of current license(s), licensure sanction(s), state(s) of current practice or intended practice, and all previous licenses held.
For telemedicine, verify licensure in state where patient is located and where the telemedicine provider is located. Must meet applicable state or local laws.
Sanctions or disciplinary actions taken by healthcare facilities, specialty boards, federal or state agencies, malpractice carriers must be reviewed for each applicant/reapplicant during the review and approval process.
For sanctions, PSV from state licensing agency/s and NPDB.
Application includes information regarding previously successful and/or currently pending (if available) challenges to any license, and/or voluntary or involuntary relinquishment of his/her license.
Can use results from search of federation of state medical boards (FSMB) disciplinary action databank or fraud and abuse control information systems (FACIS)
If telemedicine is utilized, the process for validation of licensure must be enforced (scoring procedure)

Question 4

DNV NIAHO for Hospitals
Licensure/Licensure Sanctions

Answer 4

MS.6 SR4(a)
- medical staff bylaws describe the qualifications to be met by a candidate in order for the medical staff to recommend that the governing body appoint the candidate.
- Those qualifications shall include primary source verification of current licensure on initial appointment and reappointment.
- Sanctions not specifically addressed.
- MS 6 Interpretive Guidelines state that the medical staff bylaws shall provide a mechanism for consideration of automatic suspension of clinical privileges in instances of revocation/restriction of professional license.

Question 5

URAC Health Plan
Licensure/Licensure Sanctions

Answer 5

• There must be verification of licensure or certification as minimally required to engage in clinical practice directly from the state board.
• License or certificate verifications include the expiration date, the date verified, and whether there are any sanctions on the license or certificate. The license must be current and valid when presented to the credentialing committee.
• the practitioner’s credentialing application must include state licensure information, including current license/s and history of license in all jurisdictions, and at least five years of license sanction history, if applicable.
• The NPDB or the licensing board can be used for verification of license sanctions.
  Time limit: must be verified within 180 days of the credentialing decision

Question 6

AAAHC for Ambulatory Health Care
Licensure/Licensure Sanctions

Answer 6

• Verify current state license on an ongoing basis, at a minimum at expiration, appointment and reappointment.
• Verify from primary source or secondary source
• The application includes information on licensure revocation, suspension, voluntary relinquishment, probationary status, or other conditions/limitations, and complaints or adverse action reports from licensure board and is reviewed on initial and reappointment

Question 7

Medicare Hospital COPS and Interp Guidelines

Answer 7

482.12(a)(6) and 482.22(c)(4)
The governing body must ensure that the criteria for selection of medical staff are individual character, competence, training, experience, and judgement.
- Sanctions not specifically addressed