NAMSS CPCS book Flashcards
What is NAMSS
NAMSS is celebrating more than 30 years of enhancing the professional development of and recognition for professionals in the medical staff and credentialing services field. NAMSS membership includes more than 4,500 medical staff and credentialing services professionals from medical group practices, hospitals, managed care organizations, and CVOs.
Four Topics
Principles of credentialing and re-credentialing
Operations and information management
Healthcare Law
Developing your study strategy
Factors that influence hospital credentialing
federal state law and regulations, HCQIA, Hospital COPs, State licensing regulations, accreditation standards (DNV, HFAP, TJC), hospital and medical staff bylaws or rules/regs, Standard of Care (legal aspect)
What is a Managed Care Organization
A broadly used industry term to collectively describe commercial third party payers, healthcare networks and health plans.
Variety of influences on credentialing including accreditation standards, federal/state laws/regulations, HEDIS/CAHPS, Policies & Procedures, Standard of Care (legal aspect)
What is a CVO?
Credentials Verification Organization - many factors influence the credentialing process including contracts, accreditation standards, policies and procedures, federal/state laws & regs
Two types of CVO’s
A CVO associated with a specific healthcare organization & independent CVO
Ambulatory Care, Medical Office or Surgical Center Credentialing
Structure of these organizations vary depending on size - influenced by: accreditation standards, AAAHC, HFAP, TJC, NCQA, URAC, Federal/State laws & regs, policies and procedures, contractual agreements
What is the Definition of Credentialing?
The Joint Commission defines credentialing as “the process of obtaining, verifying, and assessing the qualifications of a health care practitioner who seeks to provide patient care services in or for a hospital”.
NCQA defines credentialing as “a process by which an organization reviews and evaluates qualifications of licensed independent practitioners to provide services to its members”.
Reasons for Credentialing
Patient Safety, Risk Management Concerns, Required by Accrediting & Regulatory Agencies
Medicare Conditions of Participation
the CoP’s which are contained in the code of federal regulations, are intended to protect patient health and safety and to ensure quality of care for hospitalized patients.
Why get accredited?
accreditation assists organizations in monitoring and improving quality of care. Accrediting bodies have certain minimum requirements that have to be met in order to achieve and maintain accreditation. These requirements state that the organization must credential providers or they will not be accredited.
Organizations that are accredited are given “deemed status” meaning that they meet the Centers for Medicare and Medicaid’s requirements for participation in Medicare, Medicaid, and other federal healthcare programs.
***Being accredited doesn’t mean that the organization won’t also be subject to a state survey.
**The following hospital accreditors have been granted “deemed status”:
- The Joint Commission, AOA-HFAP, DNV
- NCQA & URAC accredit MCO’s.
*AAAHC - main accreditor for ambulatory care facilities.
Bylaws, Policies/Procedures, Rules/Regulations
regular bylaws reviews and appropriate amendments are essential to keep up with changes in accreditation standards and regulatory requirements.
Bylaw changes are not effective until approved by the governing body.
The medical staff may delegate the authority for changing the rules and regulations to the MEC.
MCO’s use policies and procedures to delineate required functions. Examples of MCO policies and procedures include credentialing, member satisfaction, medical records documentation, delegation, member’s rights and responsibilities, complaints and appeals.
Typical Procedure for Changes in Bylaws
1.) Bylaws committee meeting
2.) Input from other medical staff, administration, MSPs, attorneys
3.) To Medical Executive Committee (MEC) for review
4.) Notice to medical staff (per procedure described in bylaws)
5.) Vote by medical staff
6.) Forward to governing body for final approval
7.) Notification of change to medical staff
MCO
Main accreditor for managed care organizations or health plans are NCQA and URAC.
What is a rental network practitioner?
Used as a part of the organization’s primary network and the organization has members who reside in the rental network area
Who are specifically for out of area care and members may see only those practitioners
Who are specifically for out of area care and members are given an incentive to see rental network practitioners
What is a telemedicine practitioner
Those who have an independent relationship with the organization and who provide treatment services under the organization’s medical/behavioral benefit.
What is Stark Law
The Stark Law, also known as the Physician Self-Referral Law, is a federal law that prohibits physicians from making referrals for certain designated Health services (DHS) to entities with which they have a financial relationship, unless specific exceptions apply. The law aims to prevent self-referral practices that could lead to conflicts of interest and potential fraud in the healthcare system.
URAC standards
URAC standards require the organization verify the professional qualifications of all participating providers as well as facilities that provide covered health care services to consumers (acute inpatient facilities such as hospitals, free-standing surgical centers, home health agencies, and skilled nursing facilities).
Ambulatory Care Facility (ACF)
AAAHC requires that the governing body defines criteria for the initial appointment and reappointment of physicians and dentists.
Criteria
The requirements for appointment to a medical staff or provider panel. The basic or “core” criteria most often associated with applications for medical staff appointment or participation in managed care organizations are reflective of education, training, current competence, health status, and licensure.
Criteria should be clearly outlined in bylaws, policies and/or rules and regulations.
External Criteria
for membership are requirements set by forces outside the organization. This includes accrediting and certifying bodies such as the Joint Commission (TJC). NCQA and state and federal regulations such as the Medicare Conditions of Participation (COP’s). State licensing laws may also describe which providers can be members of the medical staff.
Internal Criteria
those factors defined by the hospital’s medical staff and governing board or the MCO’s board. This criteria may include board certification, an office within a prescribed geographic distance from the institution, alternate coverage, residence within a prescribed geographic distance from the hospital, need for a particular specialty, application fee, minimum amounts for professional liability insurance, etc.
Medicare COP requirements regarding medical staff membership
Medicare COPs require that bylaws must describe the qualifications required of a candidate in order for the medical staff to recommend appointment by the governing body. Bylaws must include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges. The COPs require a mechanism be established to examine credentials of prospective members by the medical staff. Minimum criteria for appointment to the medical staff/granting of medical staff privileges include the applicant’s character, competence, training, experience and judgement.
MCO’s appoint providers
which may include both physicians and non-physicians to a provider panel. These providers enter into a contractual arrangement with the MCO. The MCO’s policies and procedures define which providers are allowed to participate on the provider panel and the criteria used to reach a credentialing decision.
QI, QA & UM
QI= Quality Improvement
QA= Quality Assurance
UM = Utilization Management
