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What They Don’t Teach You in Medical School

(Steps in Medical Staff Credentialing)

March 13, 2008

Judi Smedra, CPMSM, CPCS

Director, Medical Staff Affairs

The University of Kansas

Hospital

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CREDENTIALING

• Process of obtaining, verifying, and

assessing the qualifications of a

healthcare practitioner to provide

patient care services in or for a

healthcare organization

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WHO’S WATCHING YOU NOW?• The Joint Commission (H)• National Practitioner Data Bank (H)• Managed Care Organizations (H)• Hospital Boards (Ultimate Authority) (H)• CMS (Medicare)• Medicare/Medicaid State

Professional Review Organizations• State Board Of Healing Arts• Managed Care Accrediting Agencies (M)• Credentials Committee (Final Decision)

(M)

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WHAT ARE THEY LOOKING FOR?• Quality Patient Care• Efficient Patient Care• Length Of Hospitalization• Legible Charts• Medical Records Compliance• Citizenship (H)• Privileges Requested Match

Privileges Performed (H)• Continuing Medical Education (CME)

Pertains To Specialty (H)

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APPLICATION PROCESS – WHAT TO EXPECT

• Group Practice Dictates Where You

Practice & How to Obtain Application

• Be Complete & Accurate

• Privileges / Membership Will Not

Be Granted Overnight!

• Expect Application Fee and/or Dues

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APPLICATION PROCESS – MAKE IT EASY ON YOURSELF!

• Account for All Time Periods – Month &

Year (must document gaps > 30 days)

• Training

• Affiliations / Work History

• Insurance Carriers

• State Licenses

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APPLICATION PROCESS – MAKE IT EASY ON YOURSELF! (continued)

• References (must be in your specialty)

• Medicare/Medicaid Provider Numbers

• NPI (National Provider Identifier)

• Signed Attestation / Release

(authorization)

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PRIVILEGES

• Will Be Required To Produce

Documentation Of Training And/Or

Experience

• Proctoring May Be Required For

Specified Time Period Or Number Of

Procedures

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DOCUMENTATION CHALLENGES

• Curriculum VitaeDates (include Month & Year)Identify Custodian of Records for Closed Training Programs/Affiliations

• LicensureKansas – Postgraduate LicenseMissouri – Temporary License for Training

• Diplomas / CertificatesMedical School, Training Programs, Boards

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DOCUMENTATION CHALLENGES(Continued)

• DEA Certificate

Prescribe/Administration of Drugs

Kansas/Missouri

• BNDD

• Change of Address

• Case Log

• Photograph For Identity

• Compliance Training/Exams (HIPAA,Privileges)

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PRIMARY SOURCE VERIFICATION• Direct Contact With Sources To

Guarantee That Statements Are Legitimate, Unchallenged & Appropriate

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TYPICAL VERIFICATION• Completed Application - All Activity

from Medical School to Present

• AMA OR AOA Profile

• Verification Of All Licensure

• Training & Competency

• Board Certification

• ECFMG (If Applicable)

• Criminal Background Check

• Malpractice Claims History

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TYPICAL VERIFICATION (Continued)• Group Practice Affiliations

• NPDB Report (H) – HIPDB Report (M)

• Peer References

• Office Of The Inspector General

• General Services Administration

• Timeframe

• Burden Of Proof Is On You!

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REAPPOINTMENT

• Provisional / Probationary (H)

• Joint Commission – Every Two Years

(H)

• NCQA (Managed Care Organizations)

– Every Three Years (M)

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MEDICAL STAFF COORDINATOR

Your Best Friend or Worst Nightmare –

Your Choice!