Master Provider Credentialing Monitoring Requirements · AMY M. NIEHAUS, MBA, CPMSM, CPCS...

Training Session Handouts

Master Provider Credentialing Monitoring

Requirements

Presented by: Amy Niehaus, MBA, CPMSM, CPCS

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Master Provider Credentialing Monitoring Requirements

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Copyright 2019 AMN Consulting, LLC. All rights reserved. These materials may not be duplicated without the express writtenpermission of AMN Consulting, LLC. 1

Ongoing Monitoring: The Who, What, Where, When, Why and How

AMY M. NIEHAUS, MBA, CPMSM, CPCS

IntroductionAmy Niehaus is a consultant, speaker and author and brings more than 25 years of credentialing and privileging experience to her work with medical staff leaders and medical services/credentialing professionals.

Amy advises clients in the areas of accreditation, regulatory compliance, credentialing, process simplification and re-design, CVO development, credentialing technology, and delegation and provides leadership and development training for medical staff leaders, and medical services, credentialing and enrollment professionals.

Ms. Niehaus has worked in multiple environments throughout her career, including acute care hospitals, CVOs, and managed care organizations. She has been a member of the National Association Medical Staff Services (NAMSS) and is dual-certified. She is a NAMSS instructor and previously served as chair of the NAMSS MCO Task Force and the NAMSS Education Committee.

Ms. Niehaus has developed and presented various programs on credentialing and privileging processes, TJC, NCQA and URAC accreditation standards, CVO certification and delegation. She is the author of “Credentialing for Managed Care: Compliant Processes for Health Plans and Delegated Entities”.




Objectives Describe CMS, TJC and NCQA requirements for ongoing monitoring

of credentials and performance Identify appropriate sources to perform ongoing monitoring List methods and tools to document and track compliance

Purpose Confirm that practitioners continue to meet organizational

requirements Confirm that practitioners are compliant with state and federal

regulations Reduce risk to the organization or practice

◦ Negligent credentialing claims◦ Accreditation or regulatory sanctions◦ Monetary fines




Regulatory/Accrediting Bodies CMS: Centers for Medicare & Medicaid Services

◦ H: Hospital ◦ MA: Medicare Advantage◦ MC: Medicaid

TJC: The Joint CommissionNCQA: National Committee for Quality Assurance

Expirables Management




Expirables Management (EM) The process of monitoring various credentials at time of renewal to

ensure continued compliance with regulatory, accreditation and organizational requirements Routinely performed by Medical Staff Services Department (MSSD)

or Credentialing Department

EM: Credentialing Elements State license DEA/CDSMalpractice insuranceOrganization-specific requirements

◦ Board certification◦ BLS/ACLS/PALS◦ Other




EM: State License CMS-H: all staff that are required by the State to be licensed must

possess a current license TJC: license required to be verified at expiration CMS-MA: not required to monitor and account for any expiration

dates on a continuous basis unless required to do so by the state; follow policiesNCQA/CMS-MC: no requirement; follow policies Leading practice: verify license at time of expiration with licensing

board

EM: DEA/CDS CMS/TJC/NCQA: no requirement; follow Bylaws or policies Leading practice: verify at expiration with primary source Sources:

◦ www.deadiversion.usdoj.gov◦ www.deanumber.com◦ AMA/AOIA Physician Profile◦ Copy of certificate




EM: Malpractice Insurance CMS/TJC/NCQA: no requirement; follow Bylaws or policies Leading practice: verify at expiration Sources:

◦ Insurance carrier◦ Copy of facesheet

EM: Board Certification CMS/TJC/NCQA: no requirement; follow Bylaws or policies Health plans may monitor to report annual board certification rates,

as well as for maintaining directory data Leading practice: verify at expiration or annual MOC reverification

date Sources:

◦ Certification board◦ Designated equivalent/authorized ABMS display agent




EM: BLS/ACLS/PALS CMS/TJC/NCQA: no requirement; follow Bylaws or policies Leading practice: verify at expiration Sources:

◦ Copy of certification card

Ongoing Monitoring




Ongoing Monitoring (OM) The process of continually monitoring, collecting and reviewing

practitioner data in between recredentialing cycles to identify potential issues that may impact the quality and safety of patient care Practitioner credentials typically monitored by MSSD or

Credentialing Department Some monitoring functions may be performed by other

departments, e.g. Quality, Risk Management, Patient Safety, Grievance Committee, Network Management, Human Resources

OM: License Sanctions CMS-H/TJC: no requirement; follow Bylaws or policies CMS-MA/MC: required to monitor sanctions and limitations on

licensure on a regular basisNCQA: must review sanction reports within 30 days of release from

source for all active licenses◦ Query source at least every 6 months if reports not published regularly◦ Query 12-18 months after last credentialing cycle if no reports published




OM: License Sanctions, cont. Leading practice: verify on a regular basis, e.g. monthly Sources:

◦ Licensing board◦ NPDB CQ◦ FSMB

OM: Medicare/Medicaid Sanctions CMS-H/TJC: no requirement; follow Bylaws or policies CMS-MA: must check each new LEIE list CMS-MC: must check the LEIE no less frequently than monthly State Medicaid Agencies: may require monitoring of state sanction

listsNCQA: must review reports within 30 days of release from source




OM: Medicare/Medicaid Sanctions, cont. Leading Practice: verify on monthly basis Sources:

◦ OIG LEIE◦ NPDB CQ◦ FSMB◦ AMA Physician Profile◦ State Medicaid agency

OIG LEIE List of Excluded Individuals and Entities (LEIE) maintained by The

Office of the Inspector General (OIG) Sanction list that identifies individuals found guilty of fraudulent

billing, misrepresentation of credentials, etc.MA organizations prohibited from hiring, continuing to employ, or

contracting with individuals named on the listUpdated monthly https://exclusions.oig.hhs.gov/




OM: Medicare Opt-Out Provider’s voluntary status to not accept federal reimbursement Valid for two years; must reapply for opt-out status if prior to

6/16/2015; otherwise automatically renews Currently 25,000+ practitioners on list

OM: Medicare Opt-Out, cont. CMS-H/TJC/CMS-MC/NCQA: no requirement; follow Bylaws or

policies CMS-MA: must check on a regular basis Leading practice: check report on a monthly basis Sources:

◦ CMS: https://data.cms.gov/Medicare-Enrollment/Opt-Out-Affidavits/7yuw-754z

◦ MAC: https://www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/MAC-Website-List.html




OM: SAM System for Award Management; formerly Excluded Parties List

System CMS-H/TJC/NCQA/CMS-MA: no requirement; follow Bylaws or

policies CMS-MC: must check no less frequently than monthly Leading practice: check website on a regular basis, e.g. monthly or

quarterly Source: www.sam.gov

OM: Preclusion List List of providers and prescribers who are precluded from receiving

payment for Medicare Advantage items and services or Part D drugs furnished or prescribed to Medicare beneficiaries CMS-MA: must check within 30 days of monthly release CMS-H/TJC/NCQA/CMS-MC: not applicable; list not currently

available to non-CMS approved MA health plans https://www.cms.gov/Medicare/Provider-Enrollment-and-

Certification/MedicareProviderSupEnroll/PreclusionList.html




OM: Complaints/Grievances CMS-H/TJC: hospital must establish a process for prompt resolution of

patient grievances CMS-MA: must develop and implement policies that address the ongoing

monitoring of grievances filed against health care professionals CMS-MC: must use data collected from its monitoring activities to

improve the performance of its managed care program, including complaints and grievances NCQA: must monitor for complaints received from its members regarding

network practitioners and investigate upon receipt as appropriate; evaluate history at least every 6 months

OM: Complaints/Grievances, cont. Leading practice: establish policies and procedures to collect,

evaluate and take appropriate action regarding complaints against practitioners in a timely manner; results should be incorporated into the performance improvement and recredentialing process as appropriate Sources:

◦ Patients/members◦ Medical staff/healthcare practitioners◦ Organization staff




OM: Adverse Events An injury that occurs while a patient/member is receiving health care services

from a practitioner CMS-H: hospital must have a quality assessment/performance improvement

program (QAPI)…and must measure, analyze, and track adverse patient events TJC: develop criteria to evaluate practitioner performance when issues

affecting the provision of safe, high quality patient care are identified, i.e. ongoing/focused professional practice evaluation (OPPE/FPPE) CMS-MA: must have an ongoing quality improvement program CMS-MC: must have in effect a monitoring system for…quality improvement NCQA: monitor at least every 6 months; may limit to primary care/high-volume

behavioral health practitioners

OM: Adverse Events, cont. Leading practice: establish policies and procedures to collect,

evaluate and take appropriate action regarding adverse events in a timely manner; results should be incorporated into the performance improvement and recredentialing process as appropriate Sources:

◦ Quality/outcomes data◦ Complaints




EM/OM Regulatory and Accrediting RequirementsCredentialing Element CMS-H TJC NCQA CMS-MA CMS-MCState License EM EM EM*License Sanctions OM OM OMDEA/CDS EM*Board Certification EM*Malpractice Insurance EM*Medicare/Medicaid Sanctions OM OM OMMedicare Opt-Out OM OMSAM OMPreclusion List OMComplaints/Grievances OM OM OM OM OMAdverse Events OM OM OM OM OM

* if required by federal/state law

EM/OM Process




EM/OM Process Develop policies and procedures Create schedule of all elements, sources and publication dates, if

availableUtilize tracking log to timely manage process (see Resources) Review routine reports from sources timely Establish communication channels with other departments

performing monitoring activities

EM/OM Tools Credentialing database reports, web crawlers or automated PSV, if

available Tools or programs to compare database files Listserv notifications Sanction monitoring vendorNPDB Continuous Query (CQ) AMA Continuous Monitoring Service




NPDB Continuous Query (CQ) Subscription service 24-hour notice of new reports Includes:

◦ License sanctions◦ Medicare/Medicaid sanctions◦ Malpractice claims◦ Disciplinary actions

Annual charge of $2.00 for each enrolled practitioner

AMA Continuous Monitoring Service Purchase or included with AMA Profiles subscription Email alert and link sent when change made to an AMA Physician Profile

previously purchased Includes:

◦ State licensure◦ National provider identifier (NPI)◦ State and federal action notification◦ DEA registration◦ ABMS® board certification◦ Medical school◦ Postgraduate medical training




Managing EM/OM Results CMS-H/TJC: medical staff evaluates and acts on reported concerns

regarding practitioner performance as defined in Bylaws and policies CMS-MA: should intervene and correct the situation when incidence of

poor quality or any type of sanction activity against a practitioner is found◦ If warranted, a site visit is performed to assess the facility

CMS-MC: must use data collected from its monitoring activities to improve the performance of its managed care program NCQA: must implement interventions when there is evidence of poor

quality that could affect patient health and safety

Managing EM/OM Results, cont. Follow Bylaws and policies Contact practitioner to confirm identity, if neededObtain additional information, if necessary Perform office site visit, if warranted Document findings and actions

◦ Credentialing database◦ Ongoing monitoring form (sample provided)




Managing EM/OM Results, cont. Action may be based on severity of issue

◦ Department Chair / Medical Director review◦ Credentialing Committee review◦ Corrective action/performance improvement plan◦ Summary suspension◦ Automatic termination

Resources CMS State Operational Manual Appendix A for Hospitals https://www.cms.gov/Regulations-

and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf TJC Comprehensive Accreditation and Certification Manual for Hospitals, effective 7/1/2019 NCQA: 2019 Health Plan Standards and Guidelines, effective 7/1/2019 CMS Medicare Managed Care Manual Chapter 6 https://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/downloads/mc86c06.pdf Electronic Code of Federal Regulations, PART 455—PROGRAM INTEGRITY: MEDICAID, Subpart E

https://ecfr.io/Title-42/pt42.4.455#sp42.4.455.e ABMS Display Agent: http://www.abms.org/media/114650/abms_displayagentlist.pdf WAMSS https://www.wamss.org/about-us/meet-us/wcsg-audit-team/ ICE https://www.iceforhealth.org/home.asp




Acronyms ABMS (American Board of Medical Specialties)

ACLS (Advanced Cardiovascular Life Support)

AMA (American Medical Association)

AOIA (American Osteopathic Information Association)

BLS (Basic Life Support)

CDS (Controlled Dangerous Substances)

CMS (Center for Medicare & Medicaid Services)

DEA (Drug Enforcement Agency)

FSMB (Federation of State Medical Boards)

MAC (Medicare Administrative Contractor)

MOC (Maintenance of Certification)

MSSD (Medical Staff Services Department)

NCQA (National Committee for Quality Assurance)

NPDB (National Practitioner Data Bank)

NPPES (National Plan and Provider Enumeration System)

NPI (National Provider Identifier)

OIG LEIE (Office of Inspector General List of Excluded Individuals and Entities)

PALS (Pediatric Advanced Life Support)

PSV (Primary Source Verification)

SAM (System for Award Management)

SSDMF (Social Security Death Master File)

TJC (The Joint Commission)

Questions?




Thank you!

Amy M. N ie haus , MBA , C PMSM, CPCSPre s ide nt , A MN Cons u l t ing , LLC(636) 432-1270amy@amn-consu l t ing l l c . comw w w. a my n ie h au s .com

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