TRANSPARENCY IS POWER HANDBOOK1...FACIS and NPDB are not competitive products. The di erence is in...

T R A N S P A R E N C Y I S P O W E RHANDBOOK1

All your credentials.All in one place.®

CheckMedic® Changing the face of credentialing - Transparency is Power2016

Printed in the United States of America. 5 4 3

ISBN 978-1-56870-656-6

No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without written permission from an authorized member of the Verisys team.

Nothing herein is intended to serve as, or should be construed as, legal advice.

In determining credentialing and screening obligations, as well as best practices for your organization, readers should rely solely on the advice of their own legal counsel.

For information about Verisys®, CheckMedic®, the MedPass®, FACIS®, please visit verisys.com, checkmedic.com or call 1-800-VERISYS (1-888-837-4797).

FACIS and NPDB are not competitive products.

The di erence is in the data.

19922016

NPDB

4,154,733

HISTORIC DATA

+2,530ADDED DAILY

+223DAILY

VERISYS has been collecting data for FACIS since 1992.

REPORTS

599,945 REPORTS

NPDB lacks signi�cant historical content.

2,500 PRIMARYSOURCES

collects data as it is published,including arrests, indictments

and initial �lings

does not except when it appears in a disciplinary record

primarily collects �naladverse action data

includes medical malpractice content

WHEN

WHAT

NPDB FACIS

NPBD collects final adverse action data only.

FACIS Collects data as it is publishing, including arrests, indictments and initial filings.

FACIS and NPDB are not competitive products.

The di erence is in the data.

19922016

NPDB

4,154,733

HISTORIC DATA

+2,530ADDED DAILY

+223DAILY

VERISYS has been collecting data for FACIS since 1992.

REPORTS

599,945 REPORTS

NPDB lacks signi�cant historical content.

2,500 PRIMARYSOURCES

collects data as it is published,including arrests, indictments

and initial �lings

does not except when it appears in a disciplinary record

primarily collects �naladverse action data

includes medical malpractice content

WHEN

WHAT

NPDB FACISLast published annual report by NPDB was in 2104 for CY 2012.

FACIS updates in real time as it pulls data from 5,200 primary sources’ publishing schedules.

NPBD is permissive use only for hospitals and payers.

FACIS’ data is available to any person or entity, allowing open access to critical data.WHO

3,500

National Provider Data Bank Fraud Abuse Control Information System

FACIS began collecting and aggregating data in 1993.

1993

MOST DATA. MOST EXPERIENCE.

The basis for all transparencyis rich, accurate, current data.

C H A N G Eis coming, no matter what

fear not

T H E M S P ’ S G U I D E TO B R I N G I N G

T H E P O W E R O F T R A N S PA R E N C Y

TO T H E C R E D E N T I A L I N G P R O C E S S

A L L C R E D E N T I A L S I N O N E P L A C E

T H E C H E C K M E D I C M E D PA S S

HANDBOOK1

Your CredentialingResource

HANDBOOK1 | Transparency is Power | CheckMedic 7

C O N T E N T SHANDBOOK1Your Credentialing Resource

0 0 I N T R O D U C T I O N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 7

0 1 T R A N S PA R E N C Y I S P O W E R . . . . . . . . . . . . . . . . . . . . . . . . . . 1 3

Transparency in health care

Resources

User Guide

0 2 A N O V E L I D E A – V E R I S Y S C O R P O R AT I O N . . . . . . 2 5

How, why, when and by whom was Verisys founded?

Who powers Verisys today?

Verisys abides by top industry standards

Why it matters to you

Mission statement and philosophy driving Verisys

“Unless someone like you

cares a whole awful lot,

nothing is going to get better.

It’s not.”

~Dr. Seuss


0 0 I N T R O D U C T I O N

I N T R O D U C T I O N

If there’s one thing about which all who work in the health care field can agree, it’s that providing the best possible patient care is a primary career motivation. Health care exists to save lives and to improve every patient’s health and well-being to the fullest extent possible, and it’s up to those who work in the medical industry to ensure that every patient receives the best possible care and enjoys the best possible outcome.

The primary gatekeepers for the safety and success of the nation’s health care facilities are the members of credentialing staffs. It is of utmost importance that practitioners are initially and will remain qualified to perform at the highest possible level, and that the doors of health care institutions are barred against unqualified, incompetent and fraudulent health care practitioners.

As those charged with verifying staff competence and compliance know all too well, whenever something goes terribly wrong—when a patient is harmed or, far worse, even dies—a good share of the blame is aimed directly at the credentialing staff. “Why did you let us hire this incompetent quack?” may well be the first question posed, and it’s aimed directly at the health care facility’s medical staff service professionals (MSPs).

10 CheckMedic | Transparency is Power | HANDBOOK1

HANDBOOK1 Your Credentialing Resource

The success of every medical facility rests on its credentialing staff’s ability to screen and verify the competence of its practitioners, both at the time of initial employment or affiliation and continuously thereafter.

There is great pressure on MSPs to keep current on credentialing best practices and legal requirements while managing engagement with an entire staff. Now, with the Affordable Care Act (ACA), more rigorous monitoring of competence with Focused and Ongoing Professional Practice Evaluation (F and OPPE), Maintenance of Certification (MOC) and more stringent board requirements for re-evaluation and re-qualification, MSPs face increasing workloads, education and training commitments and, most daunting, higher stakes and personal accountability.

Here is where the idea of taking a quantum leap in the credentialing process comes into play. What, if it could be done, would fundamentally change your process? This question is asked to invite you to reach beyond your current thinking. The field of credentialing, particularly the task of gathering and verifying applicant information, became more complex over the years and yet the overall process has not been subject to substantive and fundamental change—until now.

Verisys, a credentials verification organization (CVO), created CheckMedic®, a web-based, real-time



credentialing solution using the MedPass®, which automates and streamlines the complex, redundant task of maintaining full compliance throughout the medical staff. CheckMedic and the MedPass can help MSPs do their jobs faster and more efficiently as they deal with rapidly changing U.S. health care requirements.

Prior to CheckMedic, perhaps the most significant attempts to change the credentialing process were the emergence of the National Practitioner Data Bank (NPDB) and the American Medical Association (AMA) Master File. Yet each of these attempts to consolidate accurate practitioner information fell short of industry needs. Among other things, they simply did not contain all the information needed by a committee to assess a practitioner’s qualifications and competence.

The MedPass solves these shortcomings by providing all the information needed to make decisions regarding exclusions, compliance, competence and licensure. In essence, it is a digital, secure, and comprehensive credentials file. A file that is easily accessed by hospitals, managed care organizations, prospective employers, the

DATAV A L I D AT I O N V E R I F I C A T I O N R E A L - T I M E O N G O I N G M O N I T O R I N GA U T H E N T I C AT I O N L I C E N S I N G O N B O A R D I N G C R E D E N T I A L I N GP R I V I L E G I N G C O M P L I A N C E A G G R E G AT E C E R T I F I E D C V O S E R V I C ET E C H N O LO G Y P R I M A R Y S O U R C E M O N I T O R I N G C R E D E N T I A L I N GL I C E N S I N G O N B O A R D I N G C R E D E N T I A L I N G A G G R E G AT E C E R T I F YP R I V I L E G I N G C O M P L I A N C E A U T H E N T I C AT I O N L I C E N S I N G C V OC O M P L I A N C E A G G R E G AT E C E R T I F I E D V E R I F I C A T I O N M O N I T O R SP R I V I L E G I N G C O M P L I A N C E A G G R E G AT E C E R T I F I E D C V O S E R V I C E

checkmedic’s data and monitoring exceeds oig requirements.



military, emergency personnel and others interested in confirming and assessing provider education, training, experience, peer reviews and other evidence of competence and integrity.

So, instead of spending hours shuffling paper files, implementing digitization and making the same phone calls over and over again, MSPs can use CheckMedic’s technology to free up their valuable time to engage in more meaningful and valuable aspects of their mission.

Whether or not you feel that the time is right to engage CheckMedic, we hope that this book serves as a resource to support you in your crucially important role in the rapidly evolving field of compliance in the health care industry.

If you are ready to delegate the most time-consuming, redundant and data-driven task to Verisys through CheckMedic’s MedPass, then we are here to assist you every step of the way. We’ll help chart your course to a flawless credentialing record as well as recognition for your increasing availability for broader-level engagement in medical staff issues.





Verisys presents the case for empowering the health care industry and its associated professionals with tools that deliver

T R A N S P A R E N C Y .

CheckMedic® is a premium, turn-key data service that powers the MedPass®, the key to a health care organization’s stability, success and future.

With transparency comes integrity and confidence for the health care consumer; the regulatory compliance for health careproviders; and the sustainability and protection of Medicare, CHIP and Medicaid.

This handbook and those to follow will provide you with a practical as well as a philosophical approach to adopting and implementing an operational, systematic approach to

T R A N S P A R E N C Y .


0 1 T R A N S PA R E N C Y I S P O W E R

0 1 T R A N S P A R E N C Y

I S P O W E RTools to access the

power of transparency



0 1 T R A N S P A R E N C Y I S P O W E R

T R A N S PA R E N C Y I N H E A LT H C A R E

How you can access the power of transparency

The American health care industry has long sought a quick, reliable way to validate the credentials and competency of its providers on a continuing basis. Verisys has successfully achieved that goal!

R E S O U R C E S

Your link to current credentialing news and solutions

Your direct access to industry thought leaders who will keep you posted on news affecting your world and give you tools to manage whatever comes your way.

-John P. Benson, co-founder and COO of Verisys, provides a daily industry news feed to keep you up to speed on fraud, compliance infractions, new regulatory developments and innovative companies.

-Hugh Greeley produces Hugh’s Credentialing Digest— a monthly newsletter and blog with a priceless archive covering years of anything and everything related to credentialing.

-Craig Caddell publishes Craig’s Verification Tips— concise and useful information for verifiers. His topics cover subjects ranging from documenting your workflow to creating redundancy in the quality assurance process.



U S E R G U I D E

Keep this book handy as a reference

As much as we would love to believe you will be glued to this book, reading it from cover to cover, we know that you may focus only on what helps you be better at your job and improves your resolve to be a great MSP. This book is filled with guidelines and resources to assist you with every aspect of your mission, so keep it handy. We hope you will refer to it often. When you need another copy, let us know and we’ll send you a fresh one, as well as copies for your entire team.



T R A N S PA R E N C Y I N H E A LT H C A R E

“Truth never damages a cause that is just.”—Mahatma Ghandi

Verisys, a private company driven solely by the desire to provide the health care industry with tools to facilitate transparency, has succeeded in creating an all-encom-passing database and data aggregation set called FĀCIS® (Fraud and Abuse Control Information System), which has been relied upon by thousands of health care entities of every type, including hospital systems, long-term care facilities, laboratories, pharmaceutical companies and major pharmacy chains, since 1995.

The CheckMedic MedPass accesses FĀCIS and uses this revolutionary system as its foundation for constantly updating its data, catching anything that might impact a credentialing cycle. This includes licensure, disciplinary action, sanctions by the Centers for Medicare and Medicaid Services (CMS), criminal prosecutions and much, much more.

With transparency comes integrity and confidence for the health care consumer; regulatory compliance for health care providers; and sustainability and protection for Medicare, the Children’s Health Insurance Program (CHIP) and Medicaid.

The information included in the CheckMedic – Transparency is Power handbook series will provide you



with a practical as well as a philosophical approach to adopting and implementing an operational, systematic approach to transparency.

With a “transparency first” directive, policy creation and execution have a vital and powerful goal.

R E S O U R C E S

At Verisys, we have committed vast resources to building a comprehensive database and the tools needed to access the right amount of information when you need it and how you need it.

Yes, we are talking about the data that feeds the compli-ance machine—validation, verification, authentication and aggregation of all required information about health care providers.

But we are also talking about information that feeds your need to know what’s going on in the world of regulation, what’s up at the Office of Inspector General (OIG), what the newest developments in the implementation of the ACA are, how fraudsters are employing new schemes to cheat the system—you get the idea.

Verisys provides you with direct access to John Benson’s daily, relevant industry news feed, Hugh Greeley’s Hugh’s Credentialing Digest and Craig Caddell’s Craig’s Verification Tips.



John Benson’s daily news feed can be found at Verisys.com, on the home page. Here are the headlines of a few of one day’s linked stories that shed light on the direction of the industry:

• Health Care Fraud Prevention and Enforcement Efforts Recover Record $4 billion

• OIG: Nursing Homes Correctly Reported 53% of Abuse or Neglect Allegations in 2012

• Wheelchair Scams Exploit Medicare Fraud Risks, but What’s Next?

• Combating Medicare Fraud Proves to Be a Difficult Proposition

• NY Nursing Home to Pay $2.2M to End Medicaid Fraud Suit

• Pervasive Medicare Fraud Proves Hard to Stop

• Woman Sentenced to 8 Years in Prison for Medicare Fraud

• Biden’s Office Arrests Nursing Assistant on Patient Abuse Charges



In the next chapter, we describe Benson’s extensive experience and unique background as a hunter of fraud-sters and the creative force behind CheckMedic.

Hugh’s Credentialing Digest (hughsdigest.com) covers topics that include all aspects of credentialing. Tips on the following subjects and many, many more can be found in the archives:

• How to handle credentialing physicians who are certified by foreign boards

• How to deal with a physician’s unprofessional conduct

• How to choose a chief medical officer (CMO)

• What board certification means

• How to evaluate your hospital’s accreditation options

• How to select the right vendor for external peer review

• Why a future doctor shortage will bring new challenges to credentialing

• Admitting recommendations for teaching facilities



Hugh began his health care career in 1973 while working with the National Blue Cross Association and then with the Joint Commission on Accreditation of Hospitals (now JCAHO). He works globally to advance the cause of patient care and is widely regarded as an expert in matters pertaining to medical staff administration, hospital governance, credentialing, performance improvement, accreditation, anti-trust and corporate negligence.

Craig’s Verification Tips (craigsver-ificationtips.com) is an MSP’s best friend when it comes to screening industry expertise on verification and reference operations. Here are just a few of the subjects covered by Craig Caddell on his website:

• Value and pricing of verification and other screening services

• How to document your workflow

• How to help your workforce handle spikes in verification volume

• The benefits of membership in the National Association of Professional Background Screeners (NAPBS)



• Tips for obtaining the best possible peer references

• How to make your international verification efforts more successful

• Why validating contact information provided by applicants is crucial

• How to avoid fraudulent references

Craig is a noted screening industry expert on verification and reference operations. As vice president of ReferencePro, a provider of global verifications and reference checks that access FĀCIS, the impeccable data set powered by Verisys, he is immersed in the daily operations of global verification and reference checks. Craig is at the forefront of the development of industry verification guidelines and is recognized by NAPBS.

U S E R G U I D E

Portions of this book have been written specifically to help you propose that your board of directors adopt CheckMedic’s verification system with individual MedPasses for each practitioner. Other portions will guide you step-by-step through the implementation of this revolutionary credentialing method.



We have also included valuable content to help with the day-to-day challenges of managing a credentialing staff and implementing policy throughout an entire health care organization.

In this first chapter, you have been exposed to the concept of transparency and what it means to our country’s health care system. You are now part of a new, bigger picture that is experiencing huge changes with the implementation of the ACA and many other laws and regulations aimed at stemming fraud, waste and abuse. Your responsibilities are constantly expanding and changing, but they must start with a firm commitment to transparency.

Chapter 2 will tell you all about Verisys Corporation. When you partner with Verisys to implement the CheckMedic MedPass, your efforts are firmly backed up by a private corporation that has a profound commitment to transparency and provides the tools that the health care industry needs to support its stability and viability.

This is the first in a series of MSP handbooks that will be mailed to you when you fill out the request form in hard copy, give a Verisys representative your card or call 888-VERISYS (888-837-4797).

The other handbooks in the series have information you can use as a checklist for reviewing and refreshing your



policies, procedures and executive summary/statement of purpose. We would love to hear about your own guiding principles and how you use them to steer your efforts.

You will also receive information about how to justify implementation of the CheckMedic MedPass to the boards that must approve the budget as well as to the staff members who will participate in the program. You will learn how your staff will benefit, what this change means long term and how your organization will use the MedPass to become an enviable model within the health care industry.

These handbooks will provide you with a valuable template for any proposal requiring organization-wide adoption that you might present to the board. Examples include a digital application process or a license renewal process.

In addition, you will find detailed information about important new policies affecting your daily work, including the ACA, F and OPPE, the OIG’s Compendium of Priority Recommendations, legal resources and more.

“Whoever is careless with

the truth in small matters

cannot be trusted with important

matters.”

~Albert Einstein


0 2 A N O V E L I D E A — V E R I S Y S C O R P O R AT I O N

0 2 A N O V E L I D E A

V E R I S Y S C O R P O R A T I O N

The story of Verisys and its commitment to

the health care industry



0 2 A N O V E L I D E A - V E R I S Y S

H O W, W H Y, W H E N A N D B Y W H O M W A S V E R I S Y S F O U N D E D ?

The bold mission to reform the American health care system

• Big data starts small.• Transparency— Access to public records and information.

W H O P O W E R S V E R I S Y S T O D AY ?

Like minds join to accelerate and ensure public access to primary source data

John Benson and John O’Shaughnessy are driven by transparency. From the beginning, the company invested in ahead-of-the-curve technology to provide data on demand.

V E R I S Y S A B I D E S B Y A N D S E T S T O P I N D U S T R Y S TA N D A R D S

It’s not cheap or easy, but there’s no other way

If there’s a certification, recognition, accreditation or best practice that is relevant to credentialing, Verisys has it.



W H Y I T M AT T E R S T O Y O U

Tap into the gold standard of data to ensure 360-degree compliance

You have access to FĀCIS, the state-of-the-art database archived back to 1993.Verisys continually innovates to deliver tools that create turnkey credentialing.

M I S S I O N S TAT E M E N T A N D P H I L O S O P H Y D R I V I N G V E R I S Y S

Protect the patient by protecting the health care system

It’s ultimately the patient who benefits from compliance.



H O W, W H Y, W H E N A N D B Y W H O M W A S V E R I S Y S F O U N D E D ?

The genesis of Verisys Corporation dates back to 1992, when two former highly-placed government appointees started partnered companies that shared a bold mission to reform the American health care system through data transparency.

John O’Shaughnessy, former assistant secretary of the Department of Health and Human Services (DHHS), and Dick Kusserow, former Inspector General (IG) for DHHS, had backgrounds as solid as they come. They shared a passion to fix a system that had remained dysfunctional despite their best efforts while in public service.

The mission of their new joint venture, Government Management Services (GMS) and Strategic Management Services (SMS), was to create a database that could track disciplined medical providers as well as provide consul-tation services to help client companies build cultures of compliance.

John O’Shaughnessy, who headed GMS (which later became Verisys), has always been a pragmatic numbers man with little tolerance for bureaucracy. GMS built the crucial database known as FĀCIS®, which checks medical providers against sanctions, exclusions, debarment and disciplinary actions.



Dick Kusserow, who led SMS, the consulting portion of the venture, was known as one of President Reagan’s fabled “junkyard dogs” for his diligent pursuit of govern-ment fraud.

The fledgling companies operated out of a small office in Alexandria, Virginia, with a lean staff that had no experience with compliance and credentialing. Yet the credentialing programs that the team built have been ad-opted and continue to be the foundation of credentialing programs used by both government and private industry.

Verisys’ mission is fueled by evolving legislation aimed at curbing fraud, waste, and abuse and by enhanced en-forcement efforts. The False Claims Act (FCA), a crucial arrow in the government’s quiver, was substantially revised in 1986 and has been heavily relied upon by the feds. Other laws, including the ACA, have enhanced the government arsenal.

After making amendments to the FCA in 1986, the government started pursuing, in earnest, health care providers under that law. As IG during this period, Kus-serow was on the front lines of this campaign. Between 2000 and 2010, health care-related recoveries under the act far exceeded those in the defense sector. Today, of course, the fight against health care fraud and abuse is a daily news story. With increased federal spending on health care and defense, Forbes magazine reported that the Government Accountability Office (GAO) estimated



more than $100 billion was lost in 2013 due to improper federal payments.

B I G D ATA S TA R T S S M A L L

The core of Verisys today, FĀCIS, started with a few bits of information collected from actions taken by the attorney general’s office as a result of DHHS’s investigative and prosecutorial efforts.

The goal was to help potential client companies avoid those individuals who had previously engaged in compliance violations. Health care, an industry where people can move about freely, even after engaging in acts that violate the core tenets of moral or ethical behavior, was further harmed by the fact that health care workers could violate rules in one state and then easily move to another with impunity. Even today, states do not effectively communicate with other states, allowing unverified medical credentials to transfer easily—a clear invitation for fraud by health care workers.

Quickly realizing that the amount of data available from the federal government was sparse, GMS started reaching out to each and every state, as well as to all the medical boards that issued licenses to physicians. Building a database when there were absolutely no standards for collecting or reporting this type of information was just one of many challenges that had to be overcome.



The second biggest challenge was how to get the data into a consolidated system. The information was on paper, in newsletters and occasionally on reel-to-reel data cartridges. No agency or regulatory board that managed licensing, registrations or certifications for the delivery of health care goods and services collected or reported data, if at all, in the same manner.

Surprisingly, even within the same state, nearly every medical profession had its own board for licensing and its own disciplinary function with some level of administrative due process. Sounds simple, right? Go to 50-plus medical boards and gather disciplinary data. The GMS team quickly figured out that they had to collect data on each and every medical provider type—more than 800 across all 56 jurisdictions in the U.S.—that’s a lot of sources with no common data standard or nomenclature.

T R A N S PA R E N C Y— A C C E S S T O P U B L I C R E C O R D S A N D I N F O R M AT I O N

It was not a pretty picture—thousands of regulatory bodies across the U.S., bits and bytes of data scattered everywhere. When GMS team members asked for information, many boards asked why they wanted it and many denied access. GMS persisted in persuading recalcitrant boards of the importance of the data and the



need for transparency. It was a constant fight and a fight that was won over years and years of relentless effort.

Data technology did not come cheap in 1993. Tape readers were costly and data storage was outrageously expensive, costing $2 -$3 per megabyte (one million bytes). Then, the price for a 40-megabyte hard drive came to $100 as compared to now, when a terabyte (one trillion bytes) of storage costs about $100. Today, Verisys’ databases are multiple terabytes, which would have cost millions of dollars in 1993.

Not only was it costly to store data, building a database in 1993 was time-consuming work that required specialized skills to understand how to make the data flow into a structure that allowed it to be searched. Search algorithms were rudimentary; the leading-edge technology was Soundex, a phonetic algorithm for indexing names by sound as pronounced in English.

Despite all of the challenges, FĀCIS, the genesis of big data, was built. If O’Shaughnessy and Kusserow believed in the old saying, “Build it and they will come,” they were about to learn otherwise. Convincing the market to spend money to search a privately built and aggregated database of sanctions, exclusions, debarments and disciplinary actions was perceived as having little value—until some major health care systems were fined massive amounts of money for employing or contracting with individuals or entities the government had sanctioned.



It took time, but by 1998, FĀCIS had become the gold standard for sanctions screening. Every month, the database grew by about a thousand records and by 2006, the FĀCIS database had grown to 600,000 records. Today, thousands of records are added weekly and now the database contains millions and millions of records.

W H O P O W E R S V E R I S Y S T O D AY ?

In 2003, O’Shaughnessy and Kusserow parted ways. In 2006, John Benson, who was then managing the insurance and health care data practice of LexisNexis® Risk & Information Analytics Group, approached O’Shaughnessy and expressed interest in buying GMS on behalf of LexisNexis. The deal came close to being done, but was never completed. O’Shaughnessy and Benson, however, hit it off and developed a relationship, finding that they shared the same passion for transparency in the health care industry.

Benson’s charge while vice president at LexisNexis was SIRIS (Special Investigation Resource and Intelligence System), an application hosted by LexisNexis in partnership with NHCAA (National Health Care Anti-Fraud Association) to provide suspected fraud and abuse information-sharing across the health care industry membership.

Having spent most of his career chasing insurance



fraudsters, Benson poured his heart into trying to fix the health care abuse and fraud problem through the use of innovative technology. He had an idealistic vision—change the way the health care system operated. It was all about shining the light into dark corners, exposing bad actors and keeping them out of the system.

Benson departed LexisNexis and joined O’Shaughnessy. Together they re-branded GMS to Verisys and started building new data sets using the existing infrastructure for the FĀCIS data collection. Systems were redesigned, new servers purchased and mass storage devices built, paving the way for a broader base of data on a broader population. Verisys now collects data available on every person or business certified, registered or licensed to deliver health care goods and services throughout the entire United States. It is a herculean task, every day.

V E R I S Y S A B I D E S B Y A N D S E T S T O P I N D U S T R Y S TA N D A R D S

Right out of the gate, Benson sought certification, accreditation, recognition and compliance with every possible organization that had an existing program to set and enforce standards and best practices in the industry. While the expense had no direct return on investment and the time spent to comply with the effort exceeded that for new business development, Benson would have it no other way.



The product that Verisys would bring to market and the means by which it was developed would be immaculate in the eyes of third-party, nationally-acknowledged watchdogs.

To validate this innovative product, Verisys immediately sought certification from the National Committee for Quality Assurance (NCQA) as a CVO. At the time, CVOs didn’t do business electronically the way Verisys did, but NCQA recognized that this was the way of the future and Verisys was certified.

NCQA’s CVO certification process is a voluntary quality assessment program that health care organizations can use to assess CVOs and other organizations that verify the credentials of physicians. “Achieving CVO certification from NCQA demonstrates that Verisys has the systems, processes and personnel in place to thoroughly and accurately verify providers’ credentials and help health plan clients meet their accreditation goals,” states Margaret E. O’Kane, NCQA president.

NCQA evaluates a CVO’s management of various aspects of its data collection and verification operation, as well as the process it uses to continuously improve the services it provides. The certification process includes rigorous on-site evaluations conducted by a team of health care professionals and certified credentials specialists. A national oversight committee of physicians analyzes the team’s finding and determines certification



based on the CVO’s compliance with NCQA standards.

Verisys is governed by NCQA’s rigorous standards for certification, developed with the assistance of represen-tatives from the credentials verification industry, as well as input from managed care organizations. NCQA is an independent, not-for-profit organization dedicated to assessing and reporting on the quality of managed care plans, managed behavioral health care organizations, preferred provider organizations, new health plans, physician organizations, CVOs, disease management programs and other health-related programs. NCQA’s mission is to improve the quality of health care.

Verisys is NCQA-certified for 10 out of 10 verification services: license to practice; Drug Enforcement Administration (DEA) registration; medical board sanctions; education and training; malpractice claims history; Medicare/Medicaid sanctions; work history; practitioner application processing; CVO application and attestation content; and ongoing monitoring of sanctions.

Verisys is also fully accredited as a CVO by the Utilization Review Accreditation Commission (URAC), an indepen-dent, nonprofit organization that promotes health care quality through accreditation and certification programs. URAC’s standards keep pace with the rapid changes in the health care system and provide a mark of distinction for health care organizations that demonstrates their



commitment to quality and accountability. Through its broad-based governance structure and an inclusive standards development process, URAC ensures that all stakeholders are represented in setting meaningful stan-dards for the health care industry. “By applying for and receiving CVO accreditation, Verisys has demonstrated a commitment to quality health care. Quality health care is crucial to our nation’s welfare and it is important to have organizations that are willing to measure themselves against national standards,” according to Alan P. Spiel-man, former URAC president and CEO.

Today, Verisys checks thousands of sources in every jurisdiction for every health care provider, regulated person and regulated business on a 30-day or less revolving cycle.

Verisys is committed to the benchmark standard of primary source data that is defined by The Joint Com-mission (TJC) as “the original source.” Although TJC no longer certifies or accredits CVOs, Verisys meets all 10 key principles under TJC’s HR. 1.20.

Not satisfied with meeting the highest level of recogni-tion from existing regulatory bodies, Verisys also gained the exclusive endorsement of the American Hospital Association (AHA).

As a matter of proximity management and security as well as dedication to supporting the U.S. workforce,



Verisys is 100 percent “made in America.” American workers collect data, manage data and support the systems that deliver the data to clients.

Verisys processes millions and millions of transactions in checking and monitoring primary source information on health care providers. On the leading edge of innovation, Verisys started with annual checks and quickly increased frequency to quarterly, monthly and weekly. Now it checks in real time, making the data truly relevant.

W H Y I T M AT T E R S T O Y O U

Early on, Benson recognized that the expansive data set could be put to a valuable and more focused use. Many clients had complained about the internal credentialing process—data deficiencies, human resources (HR) pro-cess issues and compliance obligations. Each function within the client organization had its own needs, yet there was significant overlap among the various stake-holders. Benson quickly started designing a single repository for vital data.

Now that Verisys was a certified and accredited CVO, Benson overlaid the single repository idea onto the credentialing process and CheckMedic® was born. He recognized that the credentialing process was viewed by all involved as a cumbersome, yet crucial, process and in many instances remains very “old school,” with lots of



paper and requests moving among multiple parties. This is further complicated by the fact that each system asks for its own application to be completed, yet each applica-tion seeks essentially the same information.

So the overarching concept behind CheckMedic was born:

All your credentials. All in one place.®

• Do it once.

• Do it completely.

• Keep it current.

• Make it available, securely, online to any stakeholder needing it.

That required a twist—for CheckMedic to work properly, each credentialing profile had to be owned by the party about whom it had been created, not by the party re-questing the information. Lawyers and accountants, for example, like many other professionals, are responsible for maintaining their own credentials. Why not empower health care providers in the same way? Give control of their credentials to the respective health care workers and provide a platform for them to share their informa-tion with the various end-user stakeholders as needed. Much like the way a passport works, except that it can be remotely accessed. The MedPass is the digital document that holds all the information in one place and under-goes ongoing monitoring. The health care provider’s



MedPass can be accessed, with his or her permission, via an individually assigned username and password.

For this concept to work, there had to be an independent certified and accredited CVO to authenticate, verify and validate all the data contained within the credentialing file. This was, and is, a perfect role for Verisys.

Verisys continues to innovate, creating integrated systems to access data, designing products that are industry-specific and constructing custom data solutions.

M I S S I O N S TAT E M E N T A N D P H I L O S O P H Y D R I V I N G V E R I S Y S

It’s ultimately the patient who benefits from a rigorous system of compliance. You protect the patient by protecting the health care system and its institutions.

Government benefits programs such as Medicare, Medicaid and CHIP are designed to provide health care to low income and/or elderly Americans. If these programs continue to deteriorate due to fraud, waste and mismanagement, those who rely on them will remain underserved by the system and in jeopardy of receiving care at the hands of unqualified practitioners.

If health care facilities crumble under fraudulent acts of foul play, residents of rural communities could have to commute hundreds of miles for routine as well as emergency health care.



When parents put the life of their small child in the hands of a surgeon who is not trained and certified to perform an esoteric, high-risk procedure, how can any array of fines, debarment and jail time reconcile a lost life?

Verisys has patient care and justice in its focus— and abusers and fraudsters in its crosshairs.


G l o s s a r y o f A c r o n y m s

A B C D S O F D ATA Accuracy, Breadth, Currency and Depth

A C A Affordable Care Act

A C L S advanced cardiovascular life support

A H A American Hospital Association

A K A also known as

A M A American Medical Association

A M L Anti-Money Laundering Law

C D S controlled dangerous substances

C E U continuing education unit

C F O chief financial officer

C H I P Children’s Health Insurance Program

C M E comprehensive monitoring and evaluation

C M O chief medical officer

C M P civil monetary penalties

C M P L Civil Monetary Penalties Law

C M S Centers for Medicare & Medicaid Services

C O O chief operating officer

C o P Conditions of Participation


C P R cardiopulmonary resuscitation

C S R Center for Scientific Review

C V O credentials verification organization

D B A doing business as

D E A Drug Enforcement Administration

D H H S Department of Health and Human Services

D N V Det Norske Veritas

E C F M G Educational Commission for Foreign

Medical Graduates

E I N employer identification number

E K G electrocardiogram

E P O exclusive provider organization

FA C I S Fraud and Abuse Control Information System

FA C TA Fair and Accurate Credit Transactions Act

F A N D O P P E Focused and Ongoing

Professional Practice Evaluation

FA Q S frequently asked questions

F C A False Claims Act

F C R A Fair Credit Reporting Act

G L O S S A R Y O F A C R O N Y M S


F P family practice

F P P E Focused Professional Practice Evaluation

F S M B Federation of State Medical Boards

G A O Government Accountability Office

G M S Government Management Services

G S A General Services Administration

H C Q I A Health Care Quality Improvement Act

H FA P Healthcare Facilities Accreditation Program

H H S Department of Health and Human Services

H I P D B Healthcare Integrity and Protection Data Bank

H I P PA Health Insurance Portability and Accountability

Act of 1966

H M O health maintenance organization

H R human resources

I G Inspector General

I R S Internal Revenue Service

K Y C know your customer

L E I E List of Excluded Individuals/Entities

M C AT Medical College Admission Test

M C O managed care organization




M E C medical executive committee

M O C Maintenance of Certification

M S P medical staff services professional

N A P B S National Association of Professional

Background Screeners

N C Q A National Committee for Quality Assurance

N H C A A National Health Care Anti-Fraud Association

N P D B National Practitioner Data Bank

N P I national provider identifier

O P P E Ongoing Professional Practice Evaluation

PA R post-anesthesia recovery

P I private investigator

P P O preferred provider organization

S I R I S Special Investigation Resource and

Intelligence System

S M S Strategic Management Services

S S A Social Security Administration

S S N Social Security number

TJ C The Joint Commission

U R A C Utilization Review Accreditation Commission

V P M A vice president of medical affairs


Pa g e 1 o f a s a m p l e M e d Pa s s . C a l l Ve r i s y s a t 8 8 8 -V E R I S Y S ( 8 8 8 - 8 3 7- 4 7 9 7 )

f o r a c o m p l e t e s a m p l e M e d Pa s s t o a p p r e c i a t e t h e c o m p r e h e n s i v e s c o p e .


H a n d b o o k S e r i e sYou have in your hands the first in a series of handbooks designed to give you tools and information to make your job as an MSP easier.

Handbooks coming to you every several weeks include topics covering:

• The ACA and how it affects credentialing, privileging and reporting.

• F and OPPE and how to avoid redundancy by optimizing your current monitoring and peer referencing processes.

• Key steps to understanding data and building sound and sustainable best practices, due diligence documents and a code-of-conduct culture.

• Step-by-step implementation guide to harness the powerful CheckMedic tool. Stop chasing data and let it come to you with the MedPass.

• A summary of the OIG’s Compendium of Priority Recommendations that gives you a working knowledge about opportunities to reduce costs, tune up your management and ensure quality of care.

• 12 Guiding Principles that outline content to guide you when writing policy, procedure, rules and guidelines.


“This is the credentialing tool our industry has been waiting for...”

~ Anthony J. Burke, senior vice president, American Hospital Association

Register at checkmedic.com

PA R T O N E o f t h e “ C h e c k M e d i c , Tr a n s p a r e n c y i s Po w e r ”

h a n d b o o k s e r i e s i n t r o d u c e s w h y t r a n s p a r e n c y i s v i t a l l y

i m p o r t a n t t o t h e c r e d e n t i a l i n g w o r k p e r f o r m e d b y m e d i c a l

s t a f f s e r v i c e p r o f e s s i o n a l s ; p r o v i d e s a l i s t o f r e s o u r c e s

t o k e e p y o u i n f o r m e d a b o u t n e w p o l i c y a n d b r e a k i n g

n e w s ; a n d e x p l a i n s t h e o r i g i n s o f t h e Ve r i s y s C o r p o r a t i o n

a n d w h y i t s f o u n d e r s d e c i d e d t o t a k e a c t i o n t o r e f o r m t h e

A m e r i c a n h e a l t h c a r e s y s t e m t h r o u g h d a t a t r a n s p a r e n c y.

c 2016 Verisys Corporation. All rights reserved.

CRED

ENTI

AL

S VERIFICATION ORGANIZATION

Call us to see a Demo or Chat about your processes and how we can help.

888.837.4797

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