CPMSM Knowledge Check
Res Judicata
"The thing has already been decided" - You can't go back once the case has been decided and add new defendants
Voir dire
"To look and say," the plaintiff has the ability to review the hearing panel to determine conflict of interest, economic competition
Res Ipsa Loquitur
"the thing speaks for itself" (something so obvious it is clear proof. When trying to establish the "reasonableness of care", some things are so obvious that on their face, they are clear proof
Negligence: Breach of duty
# 2 If the duty to exercise do care is not met, then a breach occurs.
Who reports to NPDB other than healthcare facilities?
- State Licensing boards - ·Professional societies on physicians and dentists
Acts to mitigate Discrimination (2)
1. ADA - American with disabilities act 2. Civil Rights act
Match the items in the image
1. F 2. J 3. H 4. K 5. I 6. M 7. B 8. G 9. E 10. D
Closed Medical Staff
1. Medical staff closely monitors and restricts new application 2. Based on quality of need for patient care within the hospital and community Examples: Lab, ED, pathology hospitals sign contractual agreements with physicians or group to provide exclusive services
Hearsay Rule
A rule of evidence that restricts the admissibility of evidence that is not the personal knowledge of the witness
Consent
A voluntary act by which one person agrees to allow someone else to do something
Contract
An agreement that identifies rights and obligations
Harm or Injury
Any wrong or damage done to another, either to his/her personal rights, property
The primary purpose of performing a database audit is to:
Avoid data integrity issues
Address self-governance and accountability of the medical staff to the governing body
Bylaws
Formed by medical societies to reduce duplicative credentialing processes
CVO
Management: Control budgets and inventory
Controlling
Cluster Sample
Divides the population into groups
MCO: Which of the following activities is key to onboarding an employed practitioner? - Credentialing - Enrollment - Orientation
Enrollment
Policies and Procedures
Focus on specific functions and processes
Failure to submit re-enrollment with Medicare and Medicaid will result in what?
Loss of reimbursement
Does DNV require Credentials Committee?
No
Element of Due Process: Adherence to procedural guidelines
Procedural
Malpractice
Professional misconduct, improper discharge of professional duties or a failure to meet the standard of care by a professional that results in harm to another Failure to meet the standard of care by a professional that results in harm to another
Stark Law
Prohibits a physician who has a financial relationship with an entity from referring Medicare or Medicaid patients to that entity for the provision of a designated health service.
The process of obtaining and evaluating data to support continued membership and/or privileges of the healthcare practitioner.
Reappointment and/or Reappraisal (CMS) or Renewal of Privileges (TJC terminology)
What are the two elements of Due Process?
Substantive and Procedural
Nonfeasance
The failure to act when there is a duty to do so
The governing body delegates the oversight of credentialing, recredentialing and privileging to ___
The medical staff
Stare Decisis
To abide by the decided cases
Job Description
Work to be performed, responsibilities and skills
TJC hospital standards require that clinical privileges are hospital specific and
based on the individuals demonstrated current competence and the procedures the hospital can support
Which is the term applied to initial appointment to the medical staff to permit observation for monitoring and evaluation of physician performance? a. Temporary b. Locum tenens c. Provisional appointment
c. Provisional appointment
Malfeasance
misconduct or wrongdoing, especially by a public official
How often does HFAP require OPPE?
requires that data be collected on an ongoing basis and summarized at least 3 times during each 2 year appointment cycle
Self selected sample
type of non-probability sampling technique not leaving it up to chance
NCQA standards require the organization to have written policies and procedures that delineate certain practitioner rights and to communicate these rights to the practitioner. Name the 3 rights that must be provided to applicants.
• Right to correct erroneous information • Right to receive the status of their credentialing or recredentialing application upon request • Right to review information submitted to support their application
Corrective Action Peer Review - General Categories of Concerns
○ Clinical competence ○ Professional competence - disruptive behavior that affects quality ○ Physical and Mental Impairment ○ "Economic Factors"
Corrective Action: Peer Review
● Because of the threat of "negligent credentialing" or "corporate negligence" hospitals have the affirmative duty to select and retain only competent practitioners. ● Joint Commission requires the medical staff the take a leadership role in performance improvement activities ● Medicare COPs require performance related improvement activities aimed at practitioners. ● HCQIA outlines corrective action policies and offers immunity to peer reviewers from monetary damages
Hospital based physicians
● Hospitalists, intensivists, other hospital based physicians ● Increased risk of vicarious liability to the hospital ● Compensation must be carefully considered because it cannot be outside fair market value because of AKA ● Hospitalist's responsibilities for admitting, ED call, consulting responsibilities must be clearly outlined in the bylaws
Negligence: Duty to exercise do care
# 1 - Can be established by statute or common law. For example, the duty of physician owes to a patient is very high. the standard of care is the generally accepted level of professional care provided in community
Negligence: Proximate Cause
# 4 - it must be established that the injury was directly caused by the breach of duty
Negligence: Injury
#3 - if there is no injury incurred by the patient, there is no liability.
TJC: What elements are required to be included in a peer reference? (6)
(1) Patient Care (2) Medical Clinical Knowledge (3) Practice-based Learning (4) Interpersonal and Communication Skills (5) Professionalism (6) System-based Practice
Disciplinary action rather than termination should be used whenever possible. The managers should practice the following basic disciplinary rules (3)
- Act mediately in response to the undesired behavior - Follow the progressive steps in disciplinary action - Applied discipline consistently to all employees in the department
Initial Appointment, what 3 things should be satisfied prior to Medical Staff review and recommendation?
- Application is considered complete - Primary source verification is complete - Current competency for privileges requested is obtained (except for health plans)
Hospital Due Process (4)
- Defined in Bylaws/Rules & Regulations/ Policies - Must follow HCQIA to be protected - Includes provisions for corrective action, indications and procedures for suspension - Mechanisms may differ for members vs. non-members
Process for developing privileging criteria
- Determine what the specialty organization or manufacturer recommends or education/training or experience - Decide what specialties qualify and if any monitoring or proctoring required - Must be approved by the board prior to being offered to the practitioner
AAAHC requires a provider to be recredentialed every three years except under what circumstance?
- Every 3 years unless state law requires more frequently or - if the organization cannot recredential a practitioner within the 36 month time frame because the practitioner is on active military leave, maternity leave, or sabbatical.
Health care Quality Improvement Act
- HCQIA was passed to extend immunity to good faith peer review and creation of the NPDP passed by congress in 1986 - Only protects the review of physicians and dentists, not allied health professionals. - Created based on the decision of Patrick v Burgette
When does TJC require NPDB to be queried?
- Initial appointment - reappoitnemnt - when new privileges are requested Subsequent to the initial query, use of Continuous Query is acceptable for ongoing information.
When does HFAP require NPDB to be queried?
- Initial appointment - Reappointment
When does AAAHC require NPDB to be queried?
- Initial appointment - Reappointment Use of continuous query is acceptable
When does DNV require NPDB to be queried?
- Initial appointment - Reappointment - Temp Privileges
According to the HCQIA, at what times must the hospital query the National Practitioner Data Bank for a physician, dentist or other health care practitioner?
- Initial appointment - Reappointment (renewal) - Request for new privileges and every 2 years thereafter
TJC: How often must an organization verify licensure?
- Initial granting of privileges - Reappointment - Revision of clinical privileges - At the time of expiration
According to TJC, which items must be PSV?
- Licensure - Training - Experience - Competence
According to HFAP, what is required to grant temporary privileges?
- Licensure - DEA - Insurance - at least one recent reference
DNV: Committees
- MEC Required - Does not require credentials committee - Does not require a chief of service, department chair or medical director; the medical staff reviews. - States that the "medical Staff" reviews, does not provide a title - Does not require peer recommendations at the time of reappointment
Required Committees: HFAP
- MEC function (can assume the duties of the credentials committee) - Utilization review committee
Health Plan Due Process (4)
- Must follow HCQIA to be protected - Have clear policies and procedures - Offer the practitioner a formal appeal process - Must report action to the appropriate authorities
Boards that have an additional requirement for 1-2 years of clinical experience:
- OB/GYN -Neurological and Orthopedic Surgeries - Pathology -Physical Medicine and Rehab - Radiology - Urology
According to DNV, what is required to grant temporary privileges?
- PSV education (AMA or AOA accepted) - Clinical Competence - State license - References (2 required) - AMA, AOA, NPDB, OIG, CMS exclusions ** Cannot exceed 180 days
The preparation of budgets is part of the _____ process and the actual administration of the budget is part of the _____ process
- Planning - Control
Important policies include
- Professional Code of Conduct/Behavior - Late Career Practitioner - Low/no volume providers - Peer Review - FPPE/OPPE - Confidentiality
A hospital's duty to exercise due care is defined by several factors. Including: (5)
- State and Federal hospital licensing regulations - Applicable accreditation standards. - Medical staff and hospital bylaws, Rules and regulations and policies. - Hospital policies. - Case law.
NPDB is required for these 3 accreditations?
- TJC - HFAP - AAAHC
ACA (Affordable Care act) 2010
- The Affordable Care Act is designed to reduce healthcare costs, expand coverage for the uninsured, and increase quality of care for people across the United States. - ACA cannot by itself guarantee access or increase quality of care
Reasons for automatic termination of privileges (7)
- The staff member loses his license to practice medicine - Fails to report a restriction on his license - fails to report that license to prescribe is restricted - Fails to appear to discuss corrective actions - loses right to bill Medicare or Medicaid - Fails to complete medical records in a timely manner - Fails to maintain malpractice insurance (as required and outlined in the bylaws)
Enrollment vs Credentialing
- enrollment is the process of submitting the application and docs for the health plan or payer to use in the credentialing process - Credentialing is the processing of the application including verification and decision-making process
What are the three reasons that we conduct Performance Management?
1 to evaluate our practitioners Competence and practice for safe care of patients 2 to be in compliance with the accrediting bodies 3 to provide an objective evidence based process to support continuation of clinical privileges
What must be done according to HCQIA due process policies and procedures? (9)
1) Written notification when a professional review action has been brought against a practitioner and the reasons for the action. 2) A summary of the hearing rights and process; ability to request a hearing and the specific time period for submitting the request. 3) Allowing for at least 30 calendar days after the notification for practitioners to request a hearing; allowing representation by an attorney or another person. 4) Statement providing consequences if failing to request a hearing. 5) The organization shall promptly schedule and arrange for a hearing 6) Proper notification to the practitioner of at least 30 days prior to hearing 7) Include a summary of the Practitioner's hearing rights, list of witnesses and documents 8) Appointment of a hearing officer or a panel of individuals to review the evidence 9) Written notification of the decision that contains specific reasons for the decision
Three "hospital needed functions" for the medical staff
1-to provide patient care, 2-to evaluate & improve the quality of care provided, 3-to assess & make recommendations regarding qualifications of those who wish to provide care
Education requirements for Physicians
1. 4 years undergraduate degree 2. 4 years medical school 3. 3-7 years of residency training 4. eligible medical licenses
Categories of Medical Staff Membership (9)
1. Active Medical Staff - full and unrestricted appointment 2. Associate or Provisional Medical Staff - There is a probationary period before becoming active medical staff typically 6 -12 months 3. Consulting Medical Staff - A specialist or subspecialist who only consults on selected patients with an active staff member 4. Courtesy Medical Staff - A physician who consistently performs a limited number of procedures at a hospital. Don't take call. 5 Affiliate Medical Staff - Because of hospitalists certain primary care physicians drop active privileges, but because of managed care contracting still need to be medical staff members 6. Honorary Medical Staff - A method of recognizing the contributions of a retiring physician who has been a long term member of the medical staff 7. Emergency Department Medical Staff - Can only screen and treat patients in the ED. Usually they are independent contractors contracting with the hospital and will have limited privileges of voting etc. 8. Temp Medical Staff - those physicians who provide coverage for a physician on leave 9. Telemedical Staff- those physicians who practice telemedicine in the hospital from a remote location
NCQA-Certified or NCQA-Accredited Entities
1. Delegate must be NCQA-certified or NCQA-accredited prior to the implementation of the delegation agreement 2. For certification, the benefits are awarded for those elements/categories for which the delegate has achieved certification 3. Activities must be covered in the agreement
Solutions
1. Delivery innovation 2. Team-based care 3. Better use of tech 4. Training more physicians 5. ACA reauthorized loan repayment and forgiveness and scholarships 6. Increase in Medicare-funded GME residency slots 7. Funding for workforce planning 8. Increased funding for the public health service
What are the two key performance indicators (KPIs) or metrics?
1. Department specific indicators based on the practitioner specialty or service 2. Hospital wide indicators specific to all or most practitioners such as case volume infection control incident reports risk management data or patient survey data
4 elements of Negligence
1. Duty to exercise do care - can be established by statute or common law. For example, the duty of physician owes to a patient is very high. the standard of care is the generally accepted level of professional care provided in community 2. Breach of duty - If the duty to exercise do care is not met, then a breach occurs. 3. Injury - if there is no injury incurred by the patient, there is no liability. 4. Proximate Cause - it must be established that the injury was directly caused by the breach of duty
What are the 3 reasons we use committees?
1. Efficiency 2. Implement and document required functions 3. Evaluate and make recommendations
According to TJC, what is the correct order for application processing? (7 steps) A - Credentials Committee Review/Recommend to MEC B - Executive Committee Reviews and Recommends to Board C - Medical Director Review and Sign Off D - Verify Completeness and That All Requested Materials Are Included E - Notify Applicant of Final Decision F - Process Application: Conduct PSV and Verify Current Competency for Privileges Requested G - Board Approval H - Application Is Received I - Process Application, Conduct PSV J - Chief of Service Review and Recommend to Medical Staff K - Medical Director Review and Refer to Credentials Committee L - Credentials Committee Review/Approve M - Expedited Credentialing Sub-Committee Approval
1. H - Application Is Received 2. D - Verify Completeness and That All Requested Materials Are Included 3. F - Process Application: Conduct PSV and Verify Current Competency for Privileges Requested 4. J - Chief of Service Review and Recommend to Medical Staff 5. B - Executive Committee Reviews and Recommends to Board 6. G - Board Approval 7. E - Notify Applicant of Final Decision Remember: TJC does not require credentials committee
According to NCQA, what is the correct order for MCO application processing a clean file with Medical Director Sign off? (5 steps) A - Credentials Committee Review/Recommend to MEC B - Executive Committee Reviews and Recommends to Board C - Medical Director Review and Sign Off D - Verify Completeness and That All Requested Materials Are Included E - Notify Applicant of Final Decision F - Process Application: Conduct PSV and Verify Current Competency for Privileges Requested G - Board Approval H - Application Is Received I - Process Application, Conduct PSV J - Chief of Service Review and Recommend to Medical Staff K - Medical Director Review and Refer to Credentials Committee L - Credentials Committee Review/Approve M - Expedited Credentialing Sub-Committee Approval
1. H - Application Is Received 2. D - Verify Completeness and That All Requested Materials Are Included 3. I - Process Application, Conduct PSV 4. C - Medical Director Review and Sign Off 5. E - Notify Applicant of Final Decision If it is a clean file, it does not require credentials committee approval. Health plans do not verify current clinical competence for privileges.
According to NCQA, what is the correct order for MCO application processing that requires all files to go to the Credentialing Committee for review and decision? (5 steps) A - Credentials Committee Review/Recommend to MEC B - Executive Committee Reviews and Recommends to Board C - Medical Director Review and Sign Off D - Verify Completeness and That All Requested Materials Are Included E - Notify Applicant of Final Decision F - Process Application: Conduct PSV and Verify Current Competency for Privileges Requested G - Board Approval H - Application Is Received I - Process Application, Conduct PSV J - Chief of Service Review and Recommend to Medical Staff K - Medical Director Review and Refer to Credentials Committee L - Credentials Committee Review/Approve M - Expedited Credentialing Sub-Committee Approval
1. H - Application Is Received 2. D - Verify Completeness and That All Requested Materials Are Included 3. I - Process Application, Conduct PSV 4. L - Credentials Committee Review/Approve 5. E - Notify Applicant of Final Decision
According to TJC what are the 2 circumstances that temporary privileges can be granted?
1. Important patient care need, defined as § When the practitioners specialty is not represented and would benefit patient care § insufficient number of practitioners in a particular specialty to provide adequate care to the population 2. Initial application without issues awaiting MC recommendation
According to TJC, what is required to grant temporary privileges? (2 instances)
1. Patient Care Need - may be granted for no more than 180 days Requirements: - Documentation of the patient care need - verification of current licensure - current competency - NPDB 2. New Applicants - may not exceed 120 days Requirements: - Must be a clean file - current licensure - Training or experience - current competency - ability to perform the privileges requested - NPDB
Acts to mitigate risk: delivery of safe quality of care (3)
1. Patient safety and Quality Improvement Act. 2. Patient Protection and Affordable Care Act. 3. Health care Quality Improvement Act.
Why use NCQA-Certified or NCQA-Accredited Entities?
1. Relief from pre-delegation assessment requirements 2. Relief from the annual performance evaluation 3. Automatic credit on certain delegated activities
Why is it important to check sanctions? (4)
1. Required for corporate compliance 2. maintains eligibility for Medicare, Medicaid and other federally funded programs 3. Protects patients, staff and organizations reputations 4. Avoids Civil Monetary Penalties (CMPs)
What are the two steps in preparing a budget?
1. Specify required resources 2. Quantify costs
3 entities that can award CME
1. The AMA physician recognition award (PRA) system for all providers 2. The American osteopathic association for osteopathic physicians 3. The American academy of family practice for family practitioners
NCQA: What 3 things must be done prior to contracting with a provider and every 3 years to assess health care delivery providers? (3)
1. confirms that the provider is in good standing with state and federal regulatory bodies 2. confirms that the provider has been reviewed and approved by an accrediting body 3. conducts an on-site quality assessment, if the provider is not accredited
Board Certification (Physicians)
1.After residency, physicians can become board certified in their specialty(May require additional training and testing, American Board of Medical Specialties (ABMS), and Written and oral exam) 2. Recertification every 7-10 years
URAC standards require the organization to provide a written notification to providers within how many days of the credentialing determination?
10 business days (Note: NCQA requires within 60 calendar days)
URAC: What is the required timeframe for the organization to provide notification of the credentialing decision?
10 business days from the determination
Budgets cover what time period?
12 month
How often must providers revalidate their enrollment data in the CAQH (Council for Affordable Quality Healthcare) system?
120 days
URAC: Credentialing application signatures and PSV information cannot exceed what timeframe?
180 days or 6 months
DNV: For initial appointment, how many peer references are required?
2 on initial appointment
How many member boards does ABMS have?
24
according to Medicare COPs - Any changes in the patient's condition must be documented by the practitioner in the update note and placed in the patient's medical record within ____ hours of admission or registration.
24 hours Also - prior to surgery or a procedure requirement anesthesia services
It is best practice to prepare your budget at least how many months before implementation date?
3 months
According to HCQIA, a hospital that fails to report adverse actions may lose its immunity up to what period of time?
3 years
How often are hospitals surveyed on-site by TJC?
3 years Laboratories 2 years
You're required to report professional review actions that adversely affect clinical privileges for a period of __ days or more and this action is based on the practitioner's professional competence or conduct that adversely affects or could adversely affect the health or welfare of a patient. Both of these criteria must be met to meet the NPDB reporting requirement
30 Days
According to DNV standards, initial appointments to the medical staff are not to exceed what time period?
36 months / 3 years
During Pre-Delegation, an organization audit must include what % or # of Practitioner's file (whichever is less)
5% or 50 of its practitioners files (at least 10 credentialing & 10 reappointments or 8/30 methodology) The NCQA "8/30" methodology may be utilized in which only the first 8 files are audited if all credentialing elements score 100%. If any file element is out of compliance within the first 8 files, all remaining files must be audited for that element.
NCQA: Within how many days must a practitioner be notified of a credentialing decision for initial appointment?
60 calendar days not required for reappointment approval
Practitioner may dispute NPDB report within how many days?
60 days
HFAP: Upon receipt of a completed application, how many days must a recommendation be made to the MEC?
60 days The recommendations of the Credentials Committee (function) will be based on individual practitioner's qualifications and competency at the time the privileges are requested. All recommendations to the Medical Executive Committee (MEC) shall contain a delineation of the privileges to be extended to the applicant.
Hospitals are required to respond to patient grievances within how many days?
7 days
How far back does HFAP require a background check to include?
7 to 10 years
What is the purpose of the MAC?
A MAC (or Medicare Administrative Contractor) provides regional services on behalf of Medicare, including processing claims, enrolling providers and other activities.
Interrogatories
A part of the discovery process in which written questions are given to the opposing parties in a lawsuit to get written facts and answers given under oath to questions put forth
Prior to releasing information to a third party regarding a practitioner, the organization should acquire
A signed consent and release form
The release of liability statement signed by the applicant for medical staff appointment should include:
A statement providing immunity to those who respond in good faith to requests for information
Litigation
A trial in court to determine legal issues and the rights and duties between the parties to the litigation
Per Medicare COPs - what is the acceptable timeframe for H&P's and where must this be documented?
A. - no more than 30 days before or 24 hours after admission or registration - prior to surgery or procedure requiring anesthesia services - must be completed and documented by a physician, an oral and maxillofacial surgeon or other qualified licensed individuals in accordance with state law and hospital policy B. must be documented in the bylaws
Delegation Oversight/Annual Audit
A. There must be yearly documentation of substantive evaluation and actions plans, if needed. B. The annual audit and evaluation must be based on the responsibilities stated in the mutually agreed-upon delegation document and the appropriate NCQA standards. C. The evaluation must include a review of the delegate's credentialing policies and procedures D. An organization that conducts annual file audits of delegates one year is not required to conduct annual file audits when the delegate does not credential or re-credential any practitioner's until the next file audit is scheduled to occur. E. The organization is required to meet all other delegation oversight requirements and provide documentation that the delegate did not credential or re-credential practitioner's between the audit cycles F. Exception to Annual Audit Requirement: If the delegate is and NCQA accredited or certified organization in the areas of credentialing and re-credentialing for the elements to be included in the delegation agreement.
Which accrediting organizations do not specifically address Positive ID?
AAAHC NCQA HFAP DNV URAC Only required/addressed for TJC
ACGME
Accreditation Council of Graduate Medical Education Established in 1981, evaluates and accredits medical residency programs in the US
Bylaws
Address self-governance and accountability of the medical staff to the governing body
AAAHC: The governing body is responsible for what?
Addresses and is fully and legally responsible for the operation and performance of the organization. This can be done directly or by appropriate professional delegation.
Open Medical Staff
Admits all qualified physicians
What act prohibits discrimination against anyone aged 40 or over?
Age Discrimination and Employment Act of 1968
Federal law that prohibits discrimination based on disability and bars discrimination against a qualified individual due to the disability.
Americans with Disabilities Act (ADA) 1990
Liability
An obligation one has incurred or might incur through any act or failure to act
How often does NCQA review credentialing policies and procedures to ensure that discrimination has not occured?
Annually
Unlawful restraints and monopolies or unfair business practices.
Anti Trust Law
Formal request by a practitioner for reconsideration of an adverse action
Appeal Hearing and appeals process must comply with Healthcare Quality Improvement Act (HCQIA)
Does the TJC require background checks?
Applies to hospital employees: A criminal background check is obtained and documented for the applicant as required by law and regulation or hospital policy.
URAC: standards for complaint monitoring
As part of its recredentialing process, the organization considers any collected information regarding the participating provider's performance within the organization, including any information collected through the organization's quality management program. This may include information from sources such as complaints,
TJC: what is the timeframe that an organization must notify practitioner of privileging decision?
As specified in the bylaws
Per NCQA, within how many days must an application be completed?
As specified in the credentialing policies
HFAP: For initial appointment, how many peer references are required?
At least 1 but 3 is preferred
URAC: if credentialing delegation is used, how often must an onsite visit be conducted?
At least every three years, the organization must either conduct an on-site survey of each entity that performs credentialing functions on behalf of the organization; or if not doing an on-site review, it requests and reviews random credentialing files that must be made available within a specified amount of hours or days of the request. The organization must provide an annual report on delegated credentialing oversight to the credentialing committee that includes findings from any oversight audits performed.
URAC: How often does the credentialing committee meet?
At least quarterly and as necessary to fulfill its responsibilities
- Failure to follow bylaws, policies and procedures, accreditation requirements, state regulations. - Failure to address concerns identified in the credentialing / recredentialing process. - adopting a credentialing policy and procedure that does not reflect what a reasonable hospital would do to protect another individual from foreseeable risk of harm Are examples of what?
Breach of Duty
Provide information on the projected expenses and income associated with planned activities and whether planned activities are financially feasible
Budget
Where are Membership categories described?
Bylaws
HFAP standards require a specific document to describe the qualifications and criteria that must be met by a candidate in order for the medical staff to recommend appointment and privileges to the governing body. What is that document?
Bylaws or appended credentialing manual
Educational activities to maintain develop or increase the knowledge skills and professional performance and relationships that a physician uses to provide services for the patient public or the profession
CME
Which entity or entities have their credentialing influenced by contractual agreements and accreditation standards comprised of AAAHC, TJC and NCQA
CVO, Ambulatory care and surgery centers & health plans
Which specialty is most likely to be granted privileges for surgical management of congenital septal and valvular defects?
Cardiovascular or cardiothoracic surgeon
CMS Conditions of Participation for Hospitals require that criteria for selection to the medical staff include evaluation of five areas. One of these is competence. Name the 4 remaining areas.
Character, judgment, experience and training (Note: remember by using acronym CCJET)
The case of Darling v. Charleston Memorial Community Hospital was significant in that it set aside a long standing doctrine that was applied to hospitals. What is that doctrine?
Charitable Immunity Doctrine
According to the Joint Commission peer references must address current information regarding medical / clinical knowledge, technical and clinical skills, professionalism, interpersonal skills, communication skills and
Clinical Judgement
Used to evaluate and make recommendations regarding critical processes related to patient care and organizational functions of various departments
Committees Committees typically use meetings to carry out and document many of the functions required by accrediting or regulatory agencies and the organization's policies rules regulations and bylaws this can include documentation of credentialing and recredentialing risk management peer review and quality management/ improvement activities
In what type of organization would you typically see a "committee of the whole"?
Commonly found in smaller hospitals that are not departmentalized.
According to the Joint Commission, a department chair is required to be certified by the appropriate specialty board or have
Comparable Competency
Physician profiles to evaluate data compared to benchmark data and compared to others contents timeframes actions
Comparative Reports
The Federal Register
Contains details of proposed and recently passed federal regulations and Presidential executive orders
Management: Budgets, cost controls, business plans and resource management are included in this function.
Controlling
Management: Ensure compliance with accreditation standards and regulatory requirements
Controlling
Management: Ensures that events proceed as planned and objectives are achieved
Controlling
Management: Monitor goals and take action to ensure goals and objectives are met
Controlling
Management: Perform file audits
Controlling
Competence, Character, Judgment, Experience and Training are examples of what?
Core competencies
Which of the following terms describes an organizations responsibility to determine whether a practitioner is competent prior to granting privileges to provide patient care? - Duty to Exercise due care - Corporate Liability Doctrine - Doctrine of Respondent Superior
Corporate Liability Doctrine
AAAHC: standards for complaint monitoring
Covered under the Quality Improvement and Management standards, risk management process includes an ongoing review of patient complaints and grievances that includes defined response times, as required by law and regulation. Application must include information about complaints or adverse action reports filed against the applicant with a local, state, or national professional society or licensure board.
The process of assessing and validating the qualifications of a practitioner to provide patient care in a healthcare environment
Credentialing
Required Committees: NCQA and URAC
Credentials Committee
AAAHC: what is monitored on an ongoing basis (at expiration, appointment, and re-appointment, at minimum.)?
Date sensitive information: licensure professional liability insurance (if required) certifications DEA registrations and other such items, where applicable,
What date does NCQA use when assessing compliance with timeliness requirements for PSV?
Decision date of the Credentialing Committee meeting or medical director sign off on clean files when determining whether the 180- or 365-day requirements were met.
Allows the organizations to accredit hospitals without additional state of federal surveys
Deeming Authority Granted to TJC, HFAP and DNV
Allows the decision making body of a health care organization the ability to designate a committee or another individual to make specific decisions, related to credentialing and privileging.
Delegate authority
NCQA: The following describes what? - Mutually agreed upon - Describes the delegated activities and responsibilities of the organization and delegated entity - Requires at least semiannual reporting to the organization - Describes the process by which the organization evaluates the delegated entity's performance - Describes the remedies available to the organization of the delegated entity does not fulfill its obligations, including revocation of the delegation agreement - Organization retains the right to make the final decision
Delegated Agreement
A formal process by which the organization gives another entity the authority to perform certain functions on its behalf.
Delegation Although the organization may delegate the authority to perform a function, it may not delegate responsibility for ensuring that the function is performed appropriately.
Department budgets should relate directly to what?
Department goals The preparation of budgets is part of the PLANNING process and the actual administration of the budget is part of the CONTROLLING process
Access to credentials files should be: A. Available to all members of organization's staff B. Described fully in an access policy C. Available to any physician on staff
Described fully in an access policy
According to NCQA standards, an organization that discovers sanction information, complaints or adverse events regarding a practitioner, must take what action?
Determine if there is evidence of poor quality that could affect the health and safety of its members
Management: Organizing
Determines How work in the department would be accomplished, preparing - Identify roles and responsibilities for the staff - Assign duties to staff - Assign levels of supervision - Coordinate activities and teams to achieve departmental goals - Organize the people and material resources to design a formal structure of activities and authority
Management: Planning
Determines in advance what should be done - Determine department objectives Set goals - Formulate policies and procedures, programs, rules and regs - Develop budgets and annual meeting calendars - Schedule review and updates of governance documents - Anticipating the future and determining the best course of action to achieve those objectives.
Management: Staffing
Determines numbers, training and experience levels of employees - Assess, appoint, evaluate and develop employees - Work with HR for hiring of staff and performance appraisals - Process of acquiring, training, motivating, developing and apprising employees
Can only be granted to volunteer licensed independent practitioners when the organizations emergency operations plan has been activated?
Disaster Privileges
The following are examples of what? - Verbal Warning - Written Warning - Corrective Action Plan - Suspension
Discipline - Part of Staffing
Mahmoodian vs United
Disruptive behavior - hospital can revoke otherwise competent physician's privileges when disruptive behavior adversely affects patient care.
Elam vs College Park
Doctrine of Corporate Negligence - Med Records had information on many lawsuits against podiatrist
Boyd vs Albert Einstein
Doctrine of Ostensible Agency - HMO found liable in patient's death. Chest perforation during breast biopsy, chest pain/MI six weeks later.
Let the Master answer
Doctrine of respondent superior
What replaced the Doctrine of Charitable Immunity
Doctrine of respondent superior Darling v Community memorial hospital
This long standing legal theory places liability for an employee's actions on the employer. Thus, the hospital can be held liable for damages caused by a nurse.
Doctrine of respondent superior Replaced: Doctrine of Charitable immunity Darling v Community memorial hospital
Brief
Document an attorney prepares on appeal cases - gives history, facts, legal action, opinion about case presented to an appeals judge
Misfeasance
Doing a proper act in an unlawful or injurious manner
Course of formal proceedings carried out regularly, fairly, and in accordance with established rules and principles
Due Process Purpose: to facilitate efficient and timely due process that complies with an organization's corrective action, fair hearing, and appeals policies as well as applicable legal and regulatory requirements. Healthcare Quality Improvement Act of 1986 (HCQIA): provides immunities for peer review participants that deal with "professional review actions" and follow stringent rules and principles.
Substantive and Procedural are elements of what?
Due Process Substantive: Proof that an adverse recommendation concerning a medical staff appointee is reasonable and not arbitrary, capricious, or discriminatory Procedural: Adherence to procedural guidelines
What act requires that there be an on-call list pf physicians that can stabilize patients who present to the ED?
EMTALA - There is compensation for call - Obligation for call is generally found in the bylaws
Privileged firms possess pricing power that competitive firms lack and need not accept the price that would emerge in a competitive market. This means that privileged firms gain more from exchange than they would were they competitive.
Economic credentialing ○ Utilization of the facilities ○ Number of other physicians in the same specialty ○ Availability of beds ○ Other hospitals the physician has privileges at and the extend to which they compete
Federal "anti-dumping" law to fight hospitals transferring, discharging, or refusing to treat indigent patients coming to the emergency department because of cost factors.
Emergency Medical Treatment and Active Labor Act (EMTALA) 1986
Privileges that allow MDs to perform tasks outside of their existing privileges to save a patients life, limb or organ
Emergency privileges TJC, HFAP and AAAHC have standard that refer to emergency or disaster privileges
How will onboarding activities for non-employed and employed physicians differ? They both include: Recruitment Credentialing Privileging Orientation
Employed will also include: - Contracting - Human Resources - Underwriting - Enrollment
A joint effort between the employee and employer to enhance the existing skills of an individual as well as acquire new knowledge and skill sets.
Employee development Part of Staffing This may include: - Assign new responsibilities - Provide ongoing training - Identify new opportunities - Develop managerial skills
The process of applying to health insurance plans or payers to gain approval for participation in provider networks and to receive reimbursement for health care services provided. the process of submitting the application for payers to use in order to receive reimbursement
Enrollment Once a provider is enrolled with a payer, they can be listed in the member directory which tells a potential patient that a provider has been credentialed by the payer and can be selected
Provider Directories: What is the MCOs responsibility?
Ensure that listings are consistent with credentialing data including education training certification and specialty
Management: Controlling
Ensures that events proceed as planned and objectives are achieved - Monitor goals and take action to ensure goals and objectives are met - Control budgets and inventory - Perform file audits - Ensure compliance with accreditation standards and regulatory requirements - Budgets, cost controls, business plans and resource management are included in this function.
When developing clinical privileging criteria, what is important to evaluate?
Established standards of practice, such as specialty board recommendations
The Patient Safety and Quality Improvement Act of 2005
Establishes a voluntary reporting system designed to enhance the data available to assess and resolve patient safety and health care quality issues.
NCQA: how often do providers need to re-enroll with commercial payers?
Every 3 years
The following are examples of what and what is the management function? - Provide feedback to both individual staff and teams as a whole - empower staff to take actions and make decisions within their areas of responsibility - Listen to your employees and be open to their ideas and suggestions
Examples of Motivating Part of Staffing
How often is the Department of Health and Human services required to report exclusions from participation on Medicare, Medicaid and other Federal health care programs to the NPDB?
Exclusions are reported to the NPDB monthly
Formal proceeding at which evidence and arguments are presented on the matter to a person or body having decision-making authority
Fair Hearing Governing documents must include: • Process for scheduling hearings and appeals • Process for conducting hearings and appeals • Composition of the fair hearing panel
T/F: AAAHC is required to have a credentialing committee
False
T/F: Accreditors and federal regulations require hospitals to have service line departments?
False
T/F: FPPE is not time limited
False
T/F: Policies and Procedures require approval
False
T/F: Voluntary surrender or restriction of clinical privileges for 14 days is reportable to the NPDB
False Reportable on the 15th day
T/F HEDIS (healthcare effectiveness data and information set) is specific to URAC?
False Specific to NCQA only
T/F - for a delegated agreement MSP's do not have to submit credentialing information to payers for enrollment?
False Even though the organization is performing its own credentialing the MSP must still submit a report of credentialing information to the payer so that provider data can be loaded into the payers claim system and appear in directory
T/F: PAs are considered LIPs?
False PAs are never LIPs, their license is granted in conjunction with a supervising physician
T/F: The Joint Commission standards require that the applicant's participation in continuing education is evaluated and considered on initial appointment to the medical staff.
False. Participating in continuing education must be considered in decisions about reappointment to membership on the medical staff or renewal or revision of individual clinical privileges. The standards do not require this to be evaluated on initial appointment.
T/F: According to The Joint Commission standards if a medical staff appointee does not return their application in a timely fashion and the result is that the appointment will lapse, temporary privileges can be granted
False. Temporary privileges cannot be granted for this circumstance.
Emergency Transfer and Active Labor Act (EMTALA) 1986
Federal "anti-dumping" law to fight hospitals transferring, discharging, or refusing to treat indigent patients coming to the emergency department because of cost factors.
Americans with Disabilities Act (ADA) 1990
Federal law that prohibits discrimination based on disability and bars discrimination against a qualified individual due to the disability.
Sequence of precedence
Federal, State, Local Statutes, System bylaws, Governing Body bylaws, and Medical Staff bylaws.
Acts on behalf of its state board members in providing a national assessment program, providing tools that facilitate the documentation and distribution of credentials, sponsoring a national data base for tracking disciplinary actions, and acting as a national voice for the individual boards on issues of importance to licensing and practice
Federation of State Medical Boards The individual medical boards are responsible for licensing physicians, investigating patient complaints, and disciplining physicians who violate the law.
While privileging and credentialing, how do you process each application? On a cases by case basis or Follow a standardized process
Follow a standardized process after processing has been completed, depending on what is discovered, then you handle each item on a case by case basis
Appeal
Formal request by a practitioner for reconsideration of an adverse action
Amicus
Friend of the Court - a brief filed by an interested party giving an opinion/ information on a case
Who reviews and approves bylaws?
Governing body based on the recommendation from MEC The medical staff is responsible for writing the bylaws
Which body approves clinical privileges?
Governing body or Board
HFAP: standards for complaint monitoring
Grievances and patients complaints are reviewed through the QA/PI program. Telehealth: report adverse events and complaints to the distant site.
What specialty is most likely to be granted privileges for balloon endometrial ablation?
Gynecologist or OB-GYN
The following are belong to what policies and procedures? 1) Written notification when a professional review action has been brought against a practitioner and the reasons for the action. 2) A summary of the hearing rights and process; ability to request a hearing and the specific time period for submitting the request. 3) Allowing for at least 30 calendar days after the notification for practitioners to request a hearing; allowing representation by an attorney or another person. 4) Statement providing consequences if failing to request a hearing. 5) The organization shall promptly schedule and arrange for a hearing 6) Proper notification to the practitioner of at least 30 days prior to hearing 7) Include a summary of the Practitioner's hearing rights, list of witnesses and documents 8) Appointment of a hearing officer or a panel of individuals to review the evidence 9) Written notification of the decision that contains specific reasons for the decision
HCQIA DUE PROCESS POLICIES AND PROCEDURES
This accreditation requires an Utilization of Osteopathic Methods and Concepts Committee (OMCC) when the hospital has ten or more Dr.'s of Osteopathic Medicine who admit and manage patients?
HFAP
Which accrediting body primarily accredits osteopathic hospitals?
HFAP
Which accrediting bodies refers to AHP's as "non- physician practitioners"
HFAP For Nurse Practitioners and Physician Assistants, a collaborative agreement or supervisory agreement is required, per State regulations, with a physician who holds the same privileges being requested.
Which bodies require FPPE for all initial requests for privileges and current applicants requesting new privileges?
HFAP & TJC
According to HFAP standards, when confirming malpractice coverage the organization must
Have evidence of professional liability insurance, which includes certificate showing amounts of coverage
Purpose is to encourage good faith professional review activities.
Healthcare Quality Improvement Act of 1986
What is the federal law that was enacted for the purpose of encouraging good faith professional review activities?
Healthcare Quality Improvement Act of 1986
Authority of Hospital Corporations
Hospital boards are given authority under state law to make final decisions in credentialing matters.
Who does TJC require background checks for?
Hospital employees
AAAHC: How often must you verify insurance?
If it is required** - On an ongoing basis - initial - reapp - expiration **PSV required**
EMTALA
In 1986, Congress enacted the Emergency Medical Treatment & Active Labor Act (EMTALA) to ensure public access to emergency services regardless of ability to pay 3 elements: 1. Provide all patients with a medical screening examination (MSE) 2. Stabilize any patients with an emergency medical condition. 3. Transfer or accept appropriate patients as needed
Management: Influencing
Including motivation, coaching and problem solving - Knows and understand their staff - Influence through supervision, guidance and motivation - Find out what they want and give it to them - Influence by supervising, guiding and motivating employees
What type of CVO would have the following? - Typically for profit - Contracts with many outside organizations - Must satisfy all different accreditation requirements and needs of its customers
Independent CVO
Management: Find out what your employees want and give it to them
Influencing
Management: Influence through supervision, guidance and motivation
Influencing
Management: Knows and understand their staff
Influencing
What are some benefits of the integration of hospitals and physician groups?
Integrate: avoid some stark considerations, avoid administrative burdens, cost efficiencies, better coordination of care and improved quality and lower cost - Employee/Physicians are members of the medical staff and employees - All rules applicable to employees and medical staff apply - Hospital is responsible for negligence of physician, not just negligent credentialing
Criminal Negligence
Is the reckless disregard for the safety of another ( i.e. willful indifference to an injury that could follow an act)
Why is it important to follow HCQIA in due process?
It is imperative to follow due process and ensure that you are complying with HCQIA stringent rules to provide immunity protection.
Any individuals permitted by law and by the hospital to provide patient care services without direction or supervision
LIP Licensed independent practitioner Examples: MD, DO, DDS Some state laws include podiatrist, Dentist, Psychologist and NPs
According to the Joint Commission what disciplines require an application?
LIPs
Ostensible Agency
Legal responsibility due to appearance of control
What primary source verification is required by NCQA prior to provisional credentialing?
Licensure and 5 year malpractice history or NPDB
Under what circumstance would TJC require peer reference/recommendation at the time of reappointment?
Low/no volume providers
Developed in the early 1990s to help reduce the cost of healthcare and provide employers with competitive physician discounts for their employees
MCO Managed care organizations
DNV: If there is a MEC, the majority of members should be what?
MD's or DO's
Required Committees: TJC
MEC
What committee coordinates other committees and establishes rules that affect clinical departments?
MEC
Rules and regs require approval from
MEC & Governing body
Who must report actions to the NPDB but has no authority to query?
Malpractice insurance carriers
What medical staff committee(s) is/are required by Joint Commission hospital standards for the medical staff?
Medical Executive Committee
MAC
Medicare Administrative Contractor - Main point of contact when practitioner is enrolling in Medicare. - A MAC is a private healthcare insurer that has been awarded a geographic jurisdiction to process - Medicare Part. Pay or Part B claims. - All Medicare interactions are performed through the Mac, including enrollment. Claims processing, reimbursement and other activities. the MAC are also responsible for managing Medicare revalidation
In order for a healthcare facility to participate in the Medicare and Medicaid programs, it must comply with the:
Medicare Conditions of Participation (COPs)
The following are examples of what? - Planning - Notification - Room arrangement - Food - Agenda - Follow up - Documenting attendance - Meeting Minutes
Meeting Management Functions
____ records the conclusions, recommendations made and actions taken during a meeting.
Meeting Minutes You may write the meeting minutes prior to the meeting if it is well organized, with the exception of the recommendations and actions.
The appointment to the medical staff that grants a practitioner specific rights, responsibilities and prerogatives including voting, holding office, committee appointments and dues
Membership/Appointment
How often does TJC require OPPE?
More than once a year Most organizations provide OPPE data for every 6 to 8 months, evaluating 3 to 4 times within reappointment cycle?
What does NEC stand for?
NAMSS Ethics Committee
Which accrediting body reports annual data to the healthcare effectiveness data and information set (HEDIS)?
NCQA
Which accrediting bodies do not address CME?
NCQA URAC AAAHC
Which accrediting bodies not require/address OPPE?
NCQA URAC AAAHC
Which accrediting organizations count reapp cycle to the month not the day?
NCQA URAC
Which accrediting bodies must participate in CAHPS(consumer assessment of healthcare providers and systems)?
NCQA & URAC Accredited health plans must participate in consumer assessment of healthcare providers and systems (CAHPS), patient surveys
What two bodies have time limits on verifications?
NCQA and URAC
Which accrediting bodies will accept a copy of the DEA certificate?
NCQA and URAC NCQA will also accept documented visual inspection of the original certificate
Job Analysis
Nature and requirements for successful performance
When a hospital or other facility allows a physician to perform medical services without properly ensuring their ability to do so
Negligent Credentialing
Are CMEs relating to non-professional activities or personal interests acceptable?
No
Does DNV require peer reference/recommendation at the time of reappointment?
No
Do you have a mental or physical condition that - in any way - may impair or limit your ability to practice medicine with reasonable skill and safety with or without reasonable accommodation? Is this question permitted under the standards of the ADA?
No Language includes reference to the performance of clinical privileges
Can the medical group and the practitioner revalidate with Medicare together?
No The practitioner and the medical group will need to revalidate separately
Per NCQA, do covering practitioners (locum tenens) working longer than 90 days need to be credentialed?
No only Locum Tenens who have an independent relationship with the organization must be credentialed if they serve in this capacity for more than ninety (90) calendar days.
Can privileges be granted for services that cannot be done at the facility?
No - this is a TJC standard
Per NCQA, if a physician exclusively works in an inpatient or freestanding setting, do they require credentialing?
No, as long as they provide care resulting from the member being directed to a hospital or outpatient facility.
When does URAC require NPDB to be queried?
Not Required but can use to verify malpractice history, licensure sanctions, Medicare/Medicaid sanctions, hospital and other healthcare entity actions, and professional society actions if the organization is eligible to query the NPDB. Use of Continuous Query is acceptable.
When does NCQA require NPDB to be queried?
Not required The NPDB is an acceptable source for sanctions or limitations on licensure, Medicare/ Medicaid sanctions, and malpractice history. Use of Continuous Query is acceptable for verification of these elements and for ongoing monitoring of license sanctions and Medicare/Medicaid sanctions.
What is the work history requirement for DNV?
Not specifically addressed 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 experience.
What is the work history requirement for TJC?
Not specifically addressed - initial appointment: verification of relevant training or experience must be obtained from the primary source(s), whenever feasible - The hospital requirements are to evaluate voluntary or involuntary termination of medical staff membership and voluntary or involuntary limitation, reduction, or loss of clinical privileges.
What is the work history requirement for AAAHC?
Not specifically addressed AAAHC Sample Application for Privileges requests explanation for a break in the continuity of medical education, internship, residency, hospital affiliations, medical practice, etc.
What is the work history requirement for URAC?
Not specifically addressed, but application must include hospital affiliations and privileges.
Does DNV require an attestation statement?
Not specifically addressed.
Does TJC require an attestation statement?
Not specifically addressed.
Allows the organization to identify professional practice trends that impact quality of care and patient safety which may require intervention by the medical staff
OPPE
Expert Witness
One who has special training, experience, skill, and knowledge in a relevant area and whose testimony and opinion may be considered as evidence
What type of CVO would have the following? - Handles organization specific credentialing - May also be for-profit and have customers outside the organization
Organization specific CVO
Management: Assign levels of supervision
Organizing
Management: Coordinate activities and teams to achieve departmental goals
Organizing
Management: Determines how work in the department would be accomplished, preparing
Organizing
Management: Identify roles and responsibilities for the staff
Organizing
Telemedicine - Originating site vs Distant site
Originating site is the site where the patient is located at the time the services is provided. Distant site is the site where the practitioner providing the professional service is located
What are the enrollment periods for Medicare enrollment using a PECOS vs submitted by paper
PECOS: 45 days or less Paper: 60 days
Defendant
Party against whom legal action is brought - "One who must complain"
Plaintiff
Party bringing legal action "One who complains
This act requires that patients be allowed to participate in treatment decisions including the use of advance directives.
Patient Self-Determination Act 1990
Occurs on an annual basis and is a review of employee's job performance compared to the desired performance for the purpose of determining compensation promotion termination or additional training. Provides feedback to employees regarding their performance and help identify strengths and weaknesses they also help to motivate the employee.
Performance Evaluation - Part of staffing
The developing reviewing and preparing of practitioner performance improvement and peer reviewed data using various tools and techniques for compiling data in the hospital environment
Performance Management
Who should have access to medical staff meeting minutes?
Personnel as documented in a records access policy and procedure
What must an organization do in order to certify and award AMA PRA Category 1 Credit for educational services?
Plan and implement educational activities that meet all of the AMA PRA core requirements, be accredited by either ACCME or ACCME recognized State medical Society
Management: Anticipating the future and determining the best course of action to achieve those objectives.
Planning
Management: Determine department objectives
Planning
Management: Develop budgets and annual meeting calendars
Planning
When, in an election a candidate has a larger vote than any other candidate.
Plurality
ABMS does not certify:
Podiatrists, dentists, oral surgeons, chiropractors, and non-physician practitioners
Focus on specific functions and processes
Policies and Procedures
A licensed or certified professional who provides medical care or behavioral healthcare services
Practitioner
Discovery
Pretrial activities to determine what evidence the opposing side will present if the case comes to trial, discovery may include depositions, written interrogatories, and the inspection and copying of documents
Granting approval for an individual to perform a specific procedure or specific set of clinical and patient care activities based on documented evidence of competence in the specialty in which privileges are requested
Privileging
Which of the following terns describes a step-by-step sequence for proper completion of a task? o Policy o Procedure o Bylaws
Procedure
An institution or organization which provides services such as a hospital, residential treatment center, home health care agency or rehabilitation facility
Provider
PECOS
Provider Enrollment Chain & Ownership System MSPs should submit initial enrollment and revalidation to PECOS enrollment periods are usually 45 days or less using PECOS as compared to 60 days if submitted by paper
Medical groups, IPAs, PHOs, ACOs and CINs are all what type of healthcare entity?
Provider Organization
In order to participate in a managed care plan, a provider must be accepted to the plans
Provider panel
What is a rental network?
Providers used as part of the organization's primary network & the organization has members who reside in the rental network, out-of-area care members and those who are given incentives to see rental network patients A rental network preferred provider organization or medical discount network or silent PPO or repricer is not an insurance company; nor does it actually pay for any of the patient's medical bills. Rather, it charges a fee to non-contracted third party payers and others to access the physician's contracted rates without direct authorization or, much of the time, even the knowledge of the physician.
Sherman Anti-Trust Act 1890
Provides that: "Every contract, combination in the form of trust or otherwise, or conspiracy, in restraint of trade or commerce among the several States, or with foreign nations, is declared to be illegal."
Healthcare Quality Improvement Act of 1986
Purpose is to encourage good faith professional review activities.
What are the main functions of HR?
Recruitment and Retention
If any of the following recommendations are made, what can the practitioner do? • deny or terminate an applicant's request for initial appointment, reappointment or clinical privileges • restrict and/or suspend all, or some, of a practitioner's clinical privileges for more than 30 days, and/or • require a practitioner to obtain a consultation from a consultant whose approval is required in order for the practitioner to proceed with clinical care for more than 30 days.
Request a fair hearing
By who and when can a fair hearing be requested?
Requested by provider after an adverse recommendation is made.
Medicare requires providers to perform what process every 3-5 years?
Revalidation
narrowly focus on specific requirements Outline the standards for quality patient care
Rules and Regulations
NCQA: How often is the delegated entity required to report to the organization?
Semiannually 2x per year At a minimum the following must be included in the reports: a. progress in conducting credentialing and recredentialing activities b. performance improvement activities, if applicable
An example of a prerogative that may be granted to a physician appointed to the medical staff is: o Ability to perform a medical or surgical procedure o Hold the position of hospital chief medical officer o Serve as a chair of the bylaws committee o Not required to pay membership dues
Serve as a chair of the bylaws committee
Provides that: "Every contract, combination in the form of trust or otherwise, or conspiracy, in restraint of trade or commerce among the several States, or with foreign nations, is declared to be illegal." - landmark U.S. law that banned businesses from colluding or merging to form a monopoly
Sherman Anti-Trust Act 1890
What is the work history requirement for HFAP?
Should be obtained and verified Verification should include a confirmation of the applicant's appointment and privilege history, and any pending investigations of disciplinary actions, voluntary resignations, or relinquishments of membership/clinical privileges/contracts.
Prima Facie
So far as can be judged on the first appearance
Term describes a category of medical staff appointment that provides a basic framework within which physicians and other health care providers carry out their duties and responsibilities
Staff status
Database Audits is part of what management function?
Staffing
Management: Assess, appoint, evaluate and develop employees
Staffing
Management: Determines numbers, training and experience levels of employees
Staffing
Management: Process of acquiring, training, motivating, developing and apprising employees
Staffing
The degree of care and skill of the average healthcare practitioner who practices in the same specialty
Standard of Care
Prohibits a physician who has a financial relationship with an entity from referring Medicare or Medicaid patients to that entity for the provision of a designated health service.
Stark Law
URAC: Requires PSV for at least
State Licensure and board certification or highest level of education
Expedited Credentialing - DNV and TJC
Streamlines the governing body approval process for initial appointment and reappointment process and granting of privileges Governing body grants authority to a subcommittee to make credentialing and privileging decisions on its behalf - Must be compromised of at least 2 voting members of the governing body
Element of Due Process: Proof that an adverse recommendation concerning a medical staff appointee is reasonable and not arbitrary, capricious, or discriminatory
Substantive
Chief Resident
Supervises, manage and teach
Which accreditation entity does not use the term "Allied Health Professionals"
TJC
Which accrediting bodies do not address attestation statements?
TJC DNV
Which accrediting bodies require reappointment not to exceed 24 months?
TJC HFAP
According to The Joint Commission standards, which of the following is considered a designated equivalent source for verification of board certification?
The American Board of Medical Specialties
According to TJC, who can grant temporary privileges?
The CEO upon the recommendation of the medical staff president or authorized designee
This law was enacted in part to "enforce the constitutional right to vote, to prevent discrimination in federally assisted programs". It applies to discrimination in the medical staff application process.
The Civil Rights Act of 1964
HFAP: who can assign FPPE?
The Department Chair It can be assigned for a specific amount of cases or for a period of time. Defined in the bylaws.
Establishes a voluntary reporting system designed to enhance the data available to assess and resolve patient safety and health care quality issues.
The Patient Safety and Quality Improvement Act of 2005
Public stock corporations, who holds the board accountable?
The Stockholders
When would HFAP require a background check?
The attestation statement requests information regarding felony convictions; the questions references the last 7 - 10 years. Based on the information provided, a background check will be done or as required by state law
According to CMS and accrediting bodies, where would the hospitals and medical staff requirements for credentialing practitioners at initial appointment for membership or privileges be defined?
The bylaws
Definition: Standard of Care
The degree of care and skill of the average healthcare practitioner who practices in the same specialty
DNV: standards for complaint monitoring
The hospital must develop and implement a formal grievance procedure, which includes a referral process for quality of care issues to the Utilization Review, Quality Management or Peer Review functions, as appropriate.
According to NCQA standards, on initial application, review of information on sanctions, restrictions on licensure and limitations on scope of practice must cover what period of time?
The most recent five-year period
NCQA: who retains the right to make the final decision?
The organization
NCQA: standards for complaint monitoring
The organization must conduct ongoing monitoring that includes the collection and review of complaints and mechanisms in place to investigate practitioner- specific complaints from members upon receipt Must have evidence of an evaluation the history of complaints for all practitioners at least every 6 months
What right does NCQA provide to practitioners regarding information submitted? (3)
The organization must notify the practitioner about the - right to review information submitted to support his/her credentialing application, - to correct erroneous information, and - to be informed of the status of their credentialing or recredentialing application.
NCQA authority of delegated entity
The organization remains accountable for credentialing and recredentialingg its practitioners even it its delegates all or part of these activity The health plan makes the final decision
TJC: Are practitioners notified of credentialing decisions?
The privileging decision must be communicated to the requesting practitioner within a time frame specified in the medical staff bylaws. In the case of a denial, the applicant must be told the reason for denial.
Management
The process of accomplishing the goals of an organization through the effective use of people and other resources.
Job Specifications
The qualifications necessary to hold a particular position.
TJC: standards for complaint monitoring
There must be a process for evaluation of the credibility of a complaint, allegation, or concern against a privileged provider. Telemedicine: Report complaints to the distant site
TJC: Who develops and approves criteria to approve, grant, limit or deny a requested privilege?
These criteria are based on recommendations by the medical staff and approved by the governing body. Criteria must be directly related to the quality of health care, treatment, and services or, if criteria are not related to quality of care, there must be evidence that the impact of the resulting decisions on the quality of care, treatment, and services has been evaluated.
Patient Self-Determination Act 1990
This act requires that patients be allowed to participate in treatment decisions including the use of advance directives.
The Civil Rights Act of 1964
This law was enacted in part to "enforce the constitutional right to vote, to prevent discrimination in federally assisted programs". It applies to discrimination in the medical staff application process.
Privileged motion
This motion brings up items that are urgent - unrelated to pending business. Take precedence over all other motions.
NCQA: What is the time frame for verification of work history from credentialing decision?
Time limit: must be verified within 365 days (MCO) / 305 days (CVO) of the credentialing decision.
What act prohibits discrimination in hiring, promotion, compensation, training, or dismissal based on race, color, religion, sex, or national origin therefore employee applications cannot contain questions related to these issues?
Title VII of the Civil Rights Act of 1964
What does it mean to adopt a motion?
To accept a matter without any discussion, such as a list of practitioners due for recredentialing that meet all criteria. - Requires a second - Majority Vote Required
Which of the following is the best practice strategy for obtaining professional references? o To solely rely on the references provided by the applicant o to accept reference letters provided by the applicant o To establish a professional reference policy o to obtain professional references from peers only
To establish a professional reference policy
What is the main reason for periodically assessing appropriateness of clinical privileges for each specialty?
To protect patient safety by ensuring current competency relevance to the facility and accepted standards of care.
Medical Director
Top-level manager, evaluate clinical performance, enforce policies, liaison b/w mang. and med. staff
Negligence is a what?
Tort
an act or omission that gives rise to injury or harm to another and amounts to a civil wrong for which courts impose liability
Tort
T/F: HFAP standards allow a hospital to accept the credentialing and privileging decision of another organization (credentialing/privileging by proxy) for teleradiology services
True
When verifying board certification, what accrediting body allows the organization to rely on the verification activities of the state licensing board?
URAC & NCQA
Antitrust
Unlawful restraints and monopolies or unfair business practices
NCQA: What is considered the Credentialing decision date?
Upon approval by the Credentials committee, medical Director or an approved qualified physician designee that holds the authority to evaluate and approve files The credentialing decision is considered final even a review by the governing body is required.
Who should help pick new credentialing system?
Utilization Review Committee
Pre-Delegation Audit
When evaluating a delegate's credentialing system to ensure compatibility with your own, it is important to ensure their practice standard is equivalent with your own. This can be done by a thorough review of their policies and procedures.
Summary Suspension
Whenever there are reasonable grounds to believe that the conduct or activities of a Medical Staff member pose a threat to the life, health or safety of any patient, employee, or other and that failure to take action might result in imminent danger to such the appropriate people (peer or hospital) may summarily suspend or restrict privileges
NCQA: Licensure/Licensure Sanctions information is reviewed how often?
Within 30 days of release by the reporting entity If reports are not published on a regular basis, must query every 6 months. If not published, the organization must query the source within 12-18 months from the last credentialing cycle
According to TJC if disaster privileges are granted, how long do you have to complete PSV?
Within 72 hours of being granted disaster privileges
The following items are part of what? 1. Provisions for PHI (Protected/Private Health Information) 2. Right to Approve & Terminate 3. Responsibilities of Organization and Delegate 4. Delegated Activities 5. Semi-Annual Reporting 6. Evaluation of Performance 7. Remedies for Revocation
Written Delegation Agreements
Deposition
Written sworn testimony made before a public officer for a court action, often as answers to questions posed by a lawyer, used for discovery of information or evidence for a trial
Are you required to forward a copy of NPDB report to the state licensing board?
Yes
Does the AAAHC allow the use of a CVO?
Yes
Does the DNV require an MEC?
Yes
Is the following in the correct order of steps in a motion? 1. Motion is made 2. Motion is seconded 3. The members debate the motion 4. Presiding officer restates the motion to the assembly 5. Presiding officer asks for the affirmative votes & then the negative votes 6. The presiding officer announces the results of the voting
Yes
Per NCQA, are both Phyicians and non-physicians credenialed?
Yes
URAC: Is a credentialing committee required?
Yes
Will DNV withhold appointment/reappointment approval pending verification of CME?
Yes
There are two types of Midwife, Direct entry midwife (DEM) and Certified Nurse Midwife (CNM). Can a CNM prescribe medication?
Yes DEM - gains skills through apprenticeship
AAAHC: Can an organization accept PSV or acceptable Secondary Source verified documents from another healthcare organization?
Yes Provided it supplies directly, without transmission or involvement by the applicant or other third party, original documents or photocopies of the verification reports it has relied upon. A statement that it has performed verification is not sufficient.
Is the following acceptable under the ADA: Are you currently using any chemical substances that in any way may impair or limit your ability to practice medicine with reasonable skill and safety?
Yes Questions asked must be specifically related to clinical privileges
If the organization knew or should have known that a practitioner is not qualified and the practitioner injuries a patient through an act of negligence. Can the organization be found separately liable for the negligent credentialing of this practitioner?
Yes They can face a negligent credentialing allegation. - Darling V Charleston Community Memorial Hospital 1965 - Johnson V Misericordia Community Hospital 1991 - Kadlec Medical Center v Lakeview anesthesia associates 2008
Does the URAC require an attestation statement?
Yes attesting that the information submitted with the application is complete and accurate to the practitioner's knowledge. Time limit: must be signed and dated no more than 180 days prior to the credentials committee review.
TJC: Does TJC require positive ID?
Yes by viewing either a current picture hospital ID card or a valid picture ID issued by a state or federal, agency such as a driver's license or passport
per Medicare COPs, are there exceptions to the H&P timeframe?
Yes when the patient is receiving an outpatient surgical or procedural services and when the medical staff has developed and maintained a policy that identifies specific patients that do not require a comprehensive medical H&P, or any update to it, prior to the specific outpatient surgery or procedure. ** H&P is required for INP and OP surgery requiring anesthesia services
Does HFAP evaluate meeting attendance at the time of reappointment?
Yes, against the requirements outlines in the bylaws.
Does the HFAP require an attestation statement?
Yes, at initial and reappointment Includes: • participating in Medical Staff functions, committee activity, educational, and Quality Assessment / Performance Improvement (QAPI) activities; • abiding by bylaws, rules and regulations; and • adhering to ethical practice guidelines.
HFAP: Does HFAP evaluate OPPE?
Yes, it is factored into the decision to maintain existing privilege(s), to revise existing privilege(s), and/or to revoke an existing privilege prior to or at the time of renewal.
Does the NCQA require an attestation statement?
Yes, unless otherwise specified by state law for app and reapp regarding illegal drug use and inability to perform essential functions, history of loss or limitations of licensure or privileges or disciplinary actions, current malpractice coverage, and felony convictions. Attests that the application was correct and complete when they applied to the organization Signature stamp not accepted Time limit: must be signed within 365 days (MCO) / 305 days (CVO) ofthecredentialing decision.
According to HFAP standards, in addition to direct contact with the training program, which of the following is/are approved designated source(s) for verification of residency training? a. AMA Physicians Profile for MDs and AOA Official Osteopathic Physician Profile for DOs b. The state licensing boards if the organization confirms that the state board does verify residency c. Confirmation from an association of schools of the health
a. AMA Physicians Profile for MDs and AOA Official Osteopathic Physician Profile for DOs
Which term describes skilled and intermediate nursing facilities, hospice programs, community mental health centers, and home health care systems are designed to provide needed services in manner that is more cost effective than in a hospital? a. Alternative delivery systems b. Skilled care systems c. Managed care
a. Alternative delivery systems
Which Federal agency has been delegated the responsibility for conducting the Medicare Program? a. Centers for Medicare and Medicaid Services b. Civilian Health and Medical Program c. Federal Employee Health Benefits Program
a. Centers for Medicare and Medicaid Services
Compliance by a hospital with which of the following would be considered voluntary? a. HFAP standards b. Medicare Conditions of Participation c. State hospital licensing regulations
a. HFAP standards
According to URAC's health network standards, each applicant within the scope of the credentialing program submits an application that includes at least which of the following: a. State licensure information, including current license(s) and history of licensure in all jurisdictions b. A listing of all current and past hospital affiliations c. A NPDB self-query
a. State licensure information, including current license(s) and history of licensure in all jurisdictions
According to URAC's health network standards, each applicant within the scope of the credentialing program submits an application that includes at least which of the following a. State licensure information, including current license(s) and history of licensure in all jurisdictions b. A listing of all current and past hospital affiliations c. A NPDB self-query
a. State licensure information, including current license(s) and history of licensure in all jurisdictions
Promote Efficient Care Delivery
a. Strengthening the workforce supply coupled with innovation in role and task allocation b. Efficiency and productivity will expand the workers' capacity to deliver high- quality patient care
According to The Joint Commission standards, which of the following is an element of a self- governing medical staff? a. The medical staff determines the mechanism for establishing and enforcing criteria for assigning oversight responsibilities to practitioners with independent privileges. b. There can be any number of organized medical staffs as long as they are approved by the governing body. c. The hospital's board of directors determines the criteria for granting medical staff privileges
a. The medical staff determines the mechanism for establishing and enforcing criteria for assigning oversight responsibilities to practitioners with independent privileges.
According to The Joint Commission standards, which of the following is an element of a self- governing medical staff? a. The medical staff determines the mechanism for establishing and enforcing criteria for assigning oversight responsibilities to practitioners with independent privileges. b. There can be any number of organized medical staffs as long as they are approved by the governing body. c. The hospital's board of directors determines the criteria for granting medical staff privileges.
a. The medical staff determines the mechanism for establishing and enforcing criteria for assigning oversight responsibilities to practitioners with independent privileges.
Information is a. less complex than data. b. part of data. c. compiled from data.
a. less complex than data.
According to Joint Commission standards, the qualifications and competence of a non- employee individual, other than a PA or APRN, who is brought into the hospital by an LIP to provide care, treatment, must be assessed by a. the hospital. b. the department chairperson. c. the medical staff executive committee.
a. the hospital.
Patient-Centered Medical Home (PCMH)
an approach to delivering high-quality, cost-effective primary care. Using a patient-centered, culturally appropriate, and team-based approach, the PCMH model coordinates patient care across the health system. Puts PCP at the center of delivery of care
NCQA and MCO: What is the credentials committee responsible for?
approving and ensuring compliance with policies and procedures related to credentialing, quality improvement and risk management
HFAP: what is the timeframe for claims history review?
at least 5-year history of professional liability actions resulting in final settlements or judgments must be evaluated.
AAAHC: How often must the Governing Body Meet?
at least annually and keep minutes or records
URAC: How often does the credentialing program plan need to be updated?
at least annually by the credentialing committee
According to the Medicare COPs, how often must the surgical privileges be reviewed and updated?
at least every 2 years
According to NCQA, there must be evidence of an evaluation of the history of complaints, at least every _____
at least every 6 months
Which is an example of what would be include in a medical staff rule and regulation? a. Description of the medical staff organization including leadership b. Description of how members are appointed to the emergency room call schedule c. Qualifications for medical staff membership
b. Description of how members are appointed to the emergency room call schedule
When developing clinical privileging criteria, which of the following is important to evaluate? a. How many providers are in that specialty. b. Established standards of practice such as, specialty board recommendations. c. Whether or not the quality department can support the FPPE process.
b. Established standards of practice such as, specialty board recommendations.
You are working at an AAAHC accredited facility and you want to introduce the concept of utilizing a credentials verification organization. If the CVO is not accredited by a nationally recognized organization, you must a. Perform an initial on-site visit of the CVO to assess their capabilities and quality of work b. Perform an assessment of the capability and quality of the CVO's work c. Perform an assessment of their turn-around times
b. Perform an assessment of the capability and quality of the CVO's work
You are working at an AAAHC accredited facility and you want to introduce the concept of utilizing a credentials verification organization. If the CVO is not accredited by a nationally recognized organization, you must: a. Perform an initial on-site visit of the CVO to assess their capabilities and quality of work b. Perform an assessment of the capability and quality of the CVO's work c. Perform an assessment of their turn-around times
b. Perform an assessment of the capability and quality of the CVO's work
According to TJC, a NP functioning independently and providing medical level care must:
be granted delineated clinical privileges
Which of the following is a requirement of the Joint Commission for the medical staff? a. Participation in the Maryland Quality Indicator Project b. Reporting to the National Practitioner Data bank and state licensing board those individuals who have had privileges suspended or revoked based on quality of care concerns c. Define circumstances requiring focused review of a practitioner's performance
c. Define circumstances requiring focused review of a practitioner's performance
Which term is used to describe the use of criteria unrelated to quality of care or professional competency in determining an individual's qualifications for initial or continuing hospital medical staff appointment or privileges or continued participation in a provider panel of a managed care plan? a. Credentialing criteria b. Case management c. Economic credentialing
c. Economic credentialing
New amendments to the Medicare Conditions of Participation are officially published in the a. Journal of the American Hospital Association. b. Joint Commission of Accreditation of Healthcare Organizations Manual for Hospitals. c. Federal Register.
c. Federal Register.
According to HFAP standards, when confirming malpractice coverage the organization must: a. Query the NPDB b. Obtain the claim history with each carrier over the last five years c. Have evidence of professional liability insurance, which includes certificate showing amounts of coverage
c. Have evidence of professional liability insurance, which includes certificate showing amounts of coverage
Which term describes interns and residents in medical education programs of a teaching hospital? a. Affiliate staff b. Allied health professionals c. House staff
c. House staff
NCQA standards require the organization to verify board certification at recredentialing: a. If a practitioner has received Medicare/Medicaid sanctions. b. If a practitioner is requesting a change in status. c. In all cases.
c. In all cases. If the practitioner claims to be board certified, then you must verify
According to the DNV, if the medical staff has an executive committee, who must attend the meetings? a. Medical Staff Members and CEO b. Medical Staff Members only c. Medical Staff Members, CEO and CNO (or designee) on an ex-officio basis
c. Medical Staff Members, CEO and CNO (or designee) on an ex-officio basis
The Code of Ethics for which organization includes the language, "shall share knowledge, foster educational opportunities, and encourage personal and professional growth through continued self- improvement and applications of current advancements in the profession"? a. American Medical Association b. American Hospital Association c. NAMSS Certification Commission
c. NAMSS Certification Commission
Which term describes an organization which reviews services provided under the Medicare program to determine whether a hospital has misrepresented admission or discharge information or has taken an action that results in the unnecessary admission of an individual entitled to benefits under Medicare Part A? a. National Committee on Quality Assurance b. Joint Commission on Accreditation of Healthcare Organizations c. Peer Review Organization
c. Peer Review Organization
In addition to the Chief Executive Officer, what medical staff authority is required for granting temporary privileges. a. Medical Executive Committee b. Member of the Executive Committee, President of the Medical Staff, or Medical Director c. President of the Medical Staff
c. President of the Medical Staff according to the DNV - Must be on recommendation of a member of the medical executive committee, the president of the medical staff, or the medical director (as defined by the medical staff). Cannot exceed 120 days.
According to Joint Commission Standards, who must inform the patient about unanticipated outcomes of care, treatment, and services related to sentinel events? a. Medical staff executive committee b. Risk manager c. Responsible licensed independent practitioner or his or her designee
c. Responsible licensed independent practitioner or his or her designee
You go to the file cabinet and pick out 20 files for audit. This type of sample is called a. a cluster sample. b. a self-selected sample. c. a simple random sample.
c. a simple random sample.
In selecting a new information system, the primary consideration should be the a. cost of the system b. requirements of the user c. available technology
c. available technology
Key components of retention
care, support and development of employees
Delegate authority: URAC
credentialing committee may delegate the authority to approve clean applications to the senior clinical staff person
How often does DNV require OPPE?
data be collected periodically within the reappointment. Or as required as a part of the peer review process but does not specifically on a time frame
The primary purpose of an H&P is to
determine whether there is anything in the patient's overall condition that would affect the planned course of the patient's treatment, such as a medication allergy, or a new or existing co-morbid condition that requires additional interventions to reduce risk to the patient.
Delegate authority: TJC
governing body can use an expedited process for initial appointments and reappointments to the medical staff and when granting privileges by delegating the decision to a subcommittee of at least 2 voting governing body members
Delegate authority: DNV
governing body may elect to delegate the authority to render initial appointment reappointment and renewal or modification of clinical privileges decisions to a committee of the governing body
Corporate Liability Doctrine
hospitals may be held liable for the negligent credentialing of their nonemployee, professionally autonomous staff physicians
Performance monitoring
important in the hospital environment to evaluate a provider's competence and practice for the safe care of patients.
Borrowed Servant Doctrine
legal doctrine in which an employer is held liable for the actions of a temporary or contracted employee If a person who controls the services of another employee. The "borrowed servant", the person who controls the borrowed servant, can be held liable for the borrowed servants actions rather than the employee
NCQA: How many years of work history will be evaluated upon appointment?
minimum of 5 years PSV of work history is not required, the information is based off of the CV - Gaps > 6 months, clarify verbally or in writing - Gaps > 1 year, clarify in writing
What is the URAC time limit for verification of Licensure and licensure sanctions?
must be verified within 6 months of the credentialing decision.
Rules and Regulations
narrowly focus on specific requirements Outline the standards for quality patient care
NCQA allows for provisional credentialing (like temp privileges), what is the time frame that it may be approved?
no more than 60 calendar days. Can only be provisionally credentialed once
When does NCQA require peer references?
no specific requirement
When does URAC require peer references?
no specific requirement other than that a peer group makes the final credentialing determination.
URAC: The credentialing committee has what authority?
o Approve or disapprove applications o Delegate the authority to approve clean applications to the senior clinical staff person. This designation must be documented and include reasonable guidelines ("Clean applications" do not need to go to the Credentialing Committee);
OPPE results must be factored into what decisions (3)?
o Maintain existing privileges o Revise existing privileges o Revoke an existing privilege prior to or at the time of renewal
Which of the following elements applies to an independent CVO? Select all that apply o Must satisfy the accreditation requirements / needs of customers o Typically for-profit company o Contract with many outside organizations o Handles organization specific credentialing
o Must satisfy the accreditation requirements / needs of customers o Typically for-profit company o Contract with many outside organizations
When is FPPE required? (3)
o New applicant to confirm competence o New request for privileges o Focus on practitioner for cause
Transference of Skill
occurs when the same skills are utilized for different procedures. if a physician has not performed a specific procedure, but has performed another procedure where those skills would transfer, the medical staff may determine this
Delegate authority: NCQA
organization may have the process for the medical director or qualified physician to review and approve clean files
Delegate authority: AAAHC
the governing body may delegate the review of applications to an internal reviewer or reviewers eg the medical director or a committee that provides recommendations for appointment and reappointment to the governing body the governing body remains responsible for making appointment and reappointment decisions
Under Robert's Rules of Order, when more than one motion is proposed, which motion takes precedence?
the most recent motion takes precedence over the ones
Does the AAAHC require an attestation statement?
yes Formal statement releasing the organization from any liability in connection with credentialing decisions and includes the attestation to the accuracy and completeness of the application also includes: insurance and claims history; adverse license info; complains; denial, suspension, limitation or termination of privileges; federal actions or sanctions; conviction of criminal offense; current mental and physical health
Are peer references required by AAAHC upon initial appointment?
yes Not required for reappointment but considered to evaluate competency
Managed care organizations consist of what 3 components?
§ A health insurance plan § Delivery of care § The administration of the plan
Circumstances where, even when acting in good faith an organization could lose its immunity coverage include: (6)
§ Failure to recognize commencement of a "professional review action". § Failure to follow due process § Attempting to "plea bargain" privileges § Failure to provide a hearing whether specified in the bylaws or not § Failure to suspend a practitioner when warranted § Failure to report information as required to the NPDB
Who queries the NPDB?
· Hospitals: check accreditation standards · Other healthcare entities: at initial appointment or granting clinical privileges · State licensing boards may query at any time · Plaintiff's attorney may query under certain circumstances. If a hospital has failed to query as required. In this instance, the information obtained by the plaintiff's attorney can be used against the hospital not he practitioner · Authorized agent - CVO
What is reported to the NPDB?
· Malpractice payments from written claims or judgement · Licensure disciplinary actions for professional competence or conduct (as of March 2010, all licensure actions per section 1921) · Professional review actions for reasons relating to professional competence or conduct adversely affecting membership · Clinical privilege actions longer than 30 days or voluntary surrender or restriction of clinical privileges while under, or to avoid investigation · DEA actions can be reported, federal prosecutors can make a report, health care-related civil judgements in federal or state court can also be reported to the NPDB
Who does HCQIA extend immunity to? (5)
· professional review bodies · members/staff of those bodies · those under contract with those bodies · anyone who participates or assists the bodies with respect to action · whistleblowers
Granting privileges should be: (4)
• A documented, objective, and evidence-based process. • Based on defined criteria including training, experience and demonstrated current competence. • Based on services provided at the facility or location. • Consistently and uniformly applied for all applicants.
HFAP: when can temporary privileges be granted?
• During review and consideration of application, after completion of process for files waiting to be presented to MEC and governing body • For care of specific patient(s) • For locum tenens • For times of emergency or disaster ** Must be time limited and taken only when sufficient evidence exists
NCQA requires which three factors prior to provisionally credentialing a provider?
• PSV of a current, valid license to practice • PSV of past 5 years of malpractice claims or settlements from the malpractice carrier, or the results of the NPDB query • A current and signed application with attestation Cannot exceed 60 calendar days, at which time the full credentialing process must be completed
What do you need to evaluate clinical competence for low/no volume practitioners? (3)
• Peer recommendations • Data from other facilities • Procedure logs
For a fair hearing, what governing documents must be in place? (3)
• Process for scheduling hearings and appeals • Process for conducting hearings and appeals • Composition of the fair hearing panel
The informal resolution process
● Remedy potential problems with physicians before an event occurs - clinical or behavioral (disruptive, inappropriate, impairment) ● Once a formal investigation is undertaken it will be time consuming and costly, could affect referral patterns even if the case is ultimately dropped or won by the physician and is reportable to the NPDB ● Voluntary remediation after a discussion with a physician leader ● Can be letters of guidance, education, performance improvement plans, conditional reappointments, remedial training, counseling, evaluations, treatment or therapy
