Understanding CMS Requirements for Credentialing, Recredentialing, and Privileging in Hospitals and...

Understanding CMS Requirements for Credentialing, Recredentialing, and Privileging in Hospitals and Managed Care

Kathy Matzka, CPMSM, CPCS1304 Scott Troy Rd, Lebanon, IL 62254(618) [email protected]

CMS Hospital CoPs• All Interpretative guidelines and manuals are on

website – Rev. 137, 04-01-15 (most recent hospital)

• http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf

– Rev. 110, 10-10-14 – most recent CAH• http://cms.hhs.gov/Regulations-and-Guidance/Guidance/

Manuals/downloads/som107ap_w_cah.pdf

– Most recent rule changes for MS posted in Federal Register May 12, 2014

• http://www.gpo.gov/fdsys/pkg/FR-2014-05-12/pdf/2014-10687.pdf

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CMS Hospital Page

http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Hospitals.html

http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions.html

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Surveyor & Certification Memos

(c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com 5

Document Review – Hospital and CAH

• Medical Staff Bylaws , Rules & Regulations• Credential files to determine if the facility

complies with CMS requirements and State law, as well as, follows its own written policies for medical staff privileges and credentialing

• Personnel files to determine if staff members have the appropriate educational requirements, have had the necessary training required, and are licensed, if it is required


Medicare Conditions of ParticipationHospital and CAH

• CoPs require criteria for determining privileges and for applying the criteria:– Individual character– Individual competence– Individual training – Individual experience– Individual judgment


Hospital Sec. 482.22(a) – MS Composition

• The medical staff must be composed of MDs and DOs

• In accordance with State law, including scope-of-practice laws, the medical staff may also include other categories of physicians (as listed at § 482.12(c)(1) MD/DO/DDs/DMD/DPM/DC/OD) and non-physician practitioners who are determined to be eligible for appointment by the governing body.


Hospital IG - §482.12(a)(1)

• For physician practitioners granted privileges only, the hospital’s governing body and its medical staff must exercise oversight, such as through credentialing and competency review, of those other physician practitioners to whom it grants privileges, just as it would for those practitioners appointed to its medical staff

• CMS expects that all physician practitioners granted privileges are also appointed as unless State law limits the composition of the hospital’s medical staff to certain categories of practitioners


Survey Procedures §482.12(a)(1)

• Review documentation and verify that the governing body has determined and stated the categories of physicians and practitioners that are eligible candidates for appointment to the medical staff or to be granted medical staff privileges.


Hospital IG §482.12(a)(1)

• Other types of licensed healthcare professionals have a more limited scope of practice and usually are not eligible for hospital medical staff privileges, unless their permitted scope of practice in their State makes them more comparable to the above listed types of non-physician practitioners

• Examples: PT, OT, speech language therapist, clinical pharmacists


Hospital IG §482.12(a)(1) – Medical Staff –

• If allowed by State law non-physician practitioners may be appointed– Physician assistant– Nurse practitioner;– Clinical nurse specialist – Certified registered nurse anesthetist– Certified nurse-midwife– Clinical social worker – Clinical psychologist – Anesthesiologist’s assistant– Registered dietician or nutrition professional


Hospital §482.22(a)(2)

• MS must examine the credentials of all eligible candidates for MS membership and make recommendations to the GB on the appointment of these candidates in accordance with State law, including scope-of-practice laws, and MS bylaws, R&R

• A candidate who has been recommended by the MS and who has been appointed by the GB is subject to all MS bylaws, R&R, in addition to the requirements contained in this §482.22


Admitting privileges – Hospital and CAH

• Licensed practitioners (e.g., nurse practitioners, midwives, etc.), as allowed by the State may admit patients

• Medicare patients under care of MD, DO, DDS, DPM, OD, DC, PhD (scope of practice as permitted by law)

• If a Medicare patient is admitted by a practitioner not specified, patient is under the care of a MD/DO


Hospital IG §482.22(a)(2) Medical Staff

• The individual’s credentials to be examined must include at least: – A request for clinical privileges; – Evidence of current licensure; – Evidence of training and professional education; – Documented experience; and – Supporting references of competence.


Hospital Interpretative Guidelines §482.22(a)(2) Medical Staff

Must have a separate credentials file for each individual


Credentials Files

• What goes in?• Format (sections, tabs, etc.)• File retention policy

– How long to keep– What to keep

• Access• Electronic


Hospital Interpretative Guidelines §482.22(a)(2) Medical Staff

• It cannot be assumed that every practitioner can perform every task/activity/privilege that is specified for the applicable category of practitioner. The individual practitioner’s ability to perform each task/activity/privilege must be individually assessed

Sample Privilege Form Language

Core or Category If you do not wish to request or perform a

procedure/privilege appearing on this list, please cross it off the list and initial (or write in below).

ListPlease limit your requests to those procedure/privileges

that you will be performing at this facility and which your professional liability insurance will cover.

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(c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

Transference of Skill

• A 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 these can be grouped together

• May not apply to surgeries requiring more specialized skills or for complex surgeries not regularly performed

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CAH § 485.639 Surgical services

• If CAH provides surgical services, surgical procedures must be performed in a safe manner by qualified practitioners who have been granted clinical privileges by the GB or responsible individual in accordance with the designation requirements under this section

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Surgical Services Hospital and CAH

• Must specify the surgical privileges for each practitioner that performs surgical tasks

• MD/DO, DMD, DDS, DPM, RNFA, NP, surgical PA, surgical technicians, etc.

• If under supervision, the specific tasks/procedures and the degree of supervision (to include whether or not the supervising practitioner is physically present in the same OR, in line of sight of the practitioner being supervised) delineated in that practitioner’s surgical privileges and included on the surgical roster.

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Definition of Surgery - ACS

• “Surgery is performed for the purpose of structurally altering the human body by the incision or destruction of tissues and is part of the practice of medicine. Surgery also is the diagnostic or therapeutic treatment of conditions or disease processes by any instruments causing localized alteration or transposition of live human tissue which include lasers, ultrasound, ionizing radiation, scalpels, probes, and needles…

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Hospital IG §482.51(a)(4)

• If the hospital utilizes RNFA, surgical PA, or other non-MD/DO surgical assistants, it must establish criteria, qualifications and a credentialing process to grant specific privileges based compliance with the privileging/credentialing criteria and in accordance with Federal and State laws and regulations

• Includes surgical services tasks conducted by these practitioners while under the supervision of an MD/DO


CAH §485.639(a)

• MS bylaws include criteria for determining the privileges to be granted and procedure for applying the criteria

• Surgical privileges granted in accordance with the competencies of each practitioner

• MS appraisal procedures must evaluate each individual practitioner’s training, education, experience, and demonstrated competence as established by the CAH’S QA program, credentialing process, the practitioner’s adherence to CAH policies and procedures, and in accordance with scope of practice and other State laws and regulations


Hospital and CAH

• Surgical privileges reviewed and updated at least every 2 years

• Current roster and suspension/restriction list in surgical suite and wherever scheduling performed


Hospital IG §482.22(a)(2) Medical Staff

• Practitioner and appropriate hospital patient care areas/departments are informed of the privileges granted to the practitioner

(c) Kathy Matzka, CPMSM, CPCS www.kathymatzka.com

Communicating to Stakeholders

• Practitioners• Hospital Staff• Department chief• External entities

See sample policy and procedure

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Survey Procedures – Hospital and CAH

• Review the hospital’s method for reviewing the surgical privileges of practitioners. This method should require a written assessment of the practitioner’s training, experience, health status, and performance


Documenting Recommendations

• Use of forms• Documentation for minutes

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CAH §485.641(b)(4) Quality Assurance• The quality and appropriateness of the diagnosis and

treatment furnished by doctors of medicine or osteopathy at the CAH are evaluated by-- (i) One hospital that is a member of the network, when applicable; (ii) One QIO or equivalent entity; (iii) One other appropriate and qualified entity identified in the State rural health care plan;

• Applies to agreements with distant-site telemedicine entity

• Agreements with distant- site hospitals give that hospital responsibility


§ 482.12 CoP: Governing body - 5/14 Change

• If a hospital is part of a hospital system consisting of multiple separately certified hospitals and the system elects to have a unified and integrated medical staff must determine that this is in accordance with all applicable State and local laws

• Must meet four qualifications…


§ 482.12 CoP: Governing body - 5/14 Change• MS members holding privileges at each separately certified

hospital in the system must vote by majority either to participate in a unified and integrated medical staff structure or to opt out of such a structure

• The unified, integrated MS must have bylaws, rules, and requirements that describe – Processes for self-governance, appointment, credentialing,

privileging, and oversight– Peer review policies and due process rights guarantees– Process for medical staff members of each separately certified

hospital to be advised of their rights to opt out of the unified structure after a majority vote by the members


§ 482.12 CoP: Governing body - 5/14 Change• The unified, integrated MS must be established in a

manner that takes into account each hospital's unique circumstances, and any significant differences in patient populations served and services offered in each hospital

• The unified, integrated MS must give due consideration to the needs and concerns of members of the medical staff, regardless of practice or location, and must have mechanisms in place to ensure that issues local to particular hospitals are duly considered and addressed


§482.12 CoP: Governing body - 5/14 Change• Consult directly with individual responsible for the

organization and conduct of the hospital’s medical staff, or his or her designee

• At a minimum, consultation must occur periodically throughout the fiscal or calendar year and include discussion of matters related to the quality of medical care provided to patients of the hospital

• For a multi-hospital system with single GB, the system GB must consult directly with the individual responsible for the MS (or designee) of each hospital within its system


§ 482.12 CoP: Governing body• “Direct consultation” means that the governing body, or a

subcommittee of the governing body, meets with the leader(s) of the medical staff(s), or his/her designee(s) either face-to-face or via a telecommunications system permitting immediate, synchronous communication.

• Membership on the governing body by a medical staff member is not sufficient per se to satisfy the requirement for periodic consultation

• In such a situation the hospital meets the consultation requirement only if the medical staff member serving on the governing body is the leader of the medical staff, or his or her designee, and only if such membership includes meeting with the board periodically throughout the fiscal or calendar year and discussing matters related to the quality of medical care provided to patients of the hospital.


§ 482.28 CoP: Food and dietetic services 5/14 Change

• Patient diets, including therapeutic diets, must be ordered by one of the following:– Practitioner responsible for the care of the patient– Qualified dietitian or qualified nutrition

professional• authorized by the medical staff and • in accordance with State law governing dietitians and

nutrition professionals


§ 482.54 Condition of participation:Outpatient services(c) Standard: Orders for outpatient services. Outpatient services must be ordered by a practitioner who meets the following conditions:

(1) Is responsible for the care of the patient.(2) Is licensed in the State where he or she provides care to the patient.(3) Is acting within his or her scope of practice under State law.(4) Is authorized in accordance with policies adopted by the medical staff, and approved by the governing body, to order the applicable outpatient services. This applies to the following:– (i) All practitioners who are appointed to the hospital’s medical staff and

who have been granted privileges to order the applicable outpatient services.

– (ii) All practitioners not appointed to the medical staff, but who satisfy the above criteria for authorization by the hospital for ordering the applicable outpatient services for their patients.


Statement of Deficiencies


Hospital Deficiency Data

• http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Hospitals.html

• Downloads section at bottom of page• Full Text Statements of Deficiencies Hospital

Surveys - Updated 1/15/2015 [ZIP, 14MB]

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Hospital Deficiency Data

http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Hospitals.html


Questions ?

Comments !


MEDICARE ADVANTAGE

Medicare Managed Care – Medicare Advantage

• Title 42 ,Chapter IV, Subchapter B, Part 422 - Medicare Advantage Program Subpart E—Relationships With Providers– http://www.ecfr.gov/cgi-bin/text-idx?

SID=377e08c0984dd4046da0ab7f59667bcb&node=sp42.3.422.e&rgn=div6

• Medicare Managed Care ManualChapter 6 - Relationships With Providers– http://www.cms.gov/Regulations-and-Guidance/Guidance/

Manuals/Internet-Only-Manuals-IOMs-Items/CMS019326.html – Rev. 82, 04-27-07– Proposed Change in FR February 12, 2015 – None for credentialing

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Medicare Managed CarePage

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS019326.html


MAO – 42 Code of Federal Regulations 422.204 - Provider selection and credentialing • 42 Code of Federal Regulations 422.204 - Provider selection and

credentialing – spells out basics • MA organization has written policies and procedures for selection and

evaluation of providers• Policies must conform with the credential and recredentialing requirements

set forth in paragraph (b) of this section and with the antidiscrimination provisions set forth in § 422.205

• MA organization must follow documented process with respect to providers and suppliers who have signed contracts or participation agreements

• Differs – For providers (other than physicians and other HC professionals)– For physicians and other HC professionals, including members of physician groups

• Medicare Managed Care Manual Chapter 6 has specifics


MAO – 60.3 - Credentialing, Monitoring, and Recredentialing

• Credentialing is required for:– All physicians who provide services to the MAO’s

enrollees, including members of physician groups– All other types of HC professionals who provide

services to the MAO’s enrollees and who are permitted to practice independently under state law


MAO – 60.3 - Credentialing, Monitoring, and Recredentialing

• Credentialing is not required for:– HC professionals who are permitted to furnish

services only under the direct supervision of another practitioner

– Hospital-based HC professionals who provide services to enrollees incident to hospital services, unless those health care professionals are separately identified in enrollee literature as available to enrollees

– Students, residents, or fellows


MAO – 20.2 - Consultation in Development of Credentialing Policies

• Credentialing and recredentialing standards for types of providers and for specialists reviewed by clinical peers, through– establishment of a credentialing committee or – other mechanism

• Process for peer review when the MAO is considering employing or contracting with a provider who does not meet its established credentialing standards


MAO – 60.1 - Notice of Reason for Not Granting Participation

• MAO which declines to include a given provider or group of providers in its network, it must furnish written notice to the affected provider(s) on the reason for the decision


MAO - Initial Credentialing

• Written application• Verification of information from primary and

secondary sources• Confirmation of eligibility for payment under

Medicare• Site visits as appropriate• A limited set of procedures for newly trained

health care professionals permits initial credentialing for a period of up to 60 days


MAO – Written Application

• Completed application • Signed/dated attestation of correctness and

completeness • Information no more than six months old on the

date on which the health care professional is determined (for example, by a credentialing committee) to be eligible for appointment or contract

• All items verified prior to the appointment (exception: pending DEA)


MAO – Work History

• Includes relevant work applicable to the position being sought

• Need at least 5 years work history and a statement regarding: – Any limitations in ability to perform the functions

of the position, with or without accommodation – History of loss of license and/or felony convictions– History of loss or limitation of privileges or

disciplinary activity


MAO – Primary Source Verification Required • A current valid license to practice: Verification that the

license was in effect at the time of the credentialing decision

• Education and training - professional school and completion of a residency or specialty training, if applicable

• Board certification in each clinical specialty area for which the HC professional is credentialed

• Verification is required only for the highest level of education or training attained

• Verification of board certification is highest level provided that board does PSV of education and training


Primary Source Verification is Not Always Required • Secondary sources of information for these requirements

are widely accepted & appropriate• The sources of and methods for obtaining the designated

credentialing requirements listed are suggested appropriate sources methods - not intended as an all-inclusive listing of sources/methods that an MA organization may employ to acquire the requisite information

• Secondary source will be considered acceptable provided that the secondary source verifies the information from the originator


MAO – Clinical privileges in good standing

• Clinical privileges in good standing at the hospital designated as the primary admitting facility if applicant has admitting privileges

• Information obtained on application that lists the current status and type of admitting privileges is acceptable

• Information may be obtained by – contacting the facility– obtaining a copy of the practitioner directory – attestation by the health care professional


MAO – Malpractice Insurance

• Current, adequate malpractice insurance meeting the MAO’s requirements

• Obtained via one of the following:– malpractice carrier– copy of the insurance face sheet– attestation by the health care professional


MAO – DEA or CDS

• In effect at the time of the credentialing decision• If pending, may credential if a process under which other

DEA-certified contracted practitioners write all prescriptions that require a DEA number is adopted and implemented– Process includes verification of the newly issued DEA certificate

• Verification with – Agency issuing CDS– National Technical Information Service (NTIS) database– Obtaining a copy of the certificate

• If applicant states that he/she does not prescribe, this requirement is not applicable


MAO – Claims/NPDB/Sanctions/Eligibility

• A history of professional liability claims resulting in settlements or judgments paid by or on behalf of the health care professional– can be obtained from the malpractice carrier or NPDB

• For physicians NPDB• Information about sanctions or limitations on

licensure from the applicable state licensing agency or board, or from a group such as FSMB

• Eligibility for participation in Medicare


MAO – 60.2 - Confirmation of Eligibility for Participation in Medicare

• Excluded and Opt-Out Provider Checks – Office of the Inspector General (OIG) sanction list – Opt-out of Medicare info obtained from the local

Medicare Part B carrier - must check this list “on a regular basis”


MAO – Site Visits

• CMS does not require MAOs to conduct initial credentialing or recredentialing site visits

• Must establish a policy for conducting site visits– Frequency of site visits– Procedures for detecting deficiencies/mechanisms to address

deficiencies – Should “consider” requiring initial credentialing site visits of the

offices of primary care practitioners, obstetrician-gynecologists, or other high-volume providers, as defined by the MA organization

• Visit should include an evaluation of the site’s accessibility, appearance, and adequacy of equipment, medical record keeping practices and the confidentiality requirements


MAO – Initial Requirements for a Newly Trained HC Professional• Completed all appropriate training and education within the

last 12 months• Have a policy that permits initial credentialing for a period of

up to 60 days with verification of – current, valid license from primary sources; – malpractice settlements from the last 5 years by verifying with the

malpractice carrier or NPDB (attestation not accepted)• P&P which ensures that the practitioner meets all standard

credentialing requirements after 60 days• Credentialing Committee reviews and makes final

determination about granting such an initial 60-day credentialing period


MAO – Ongoing Monitoring• Develop and implement policies that address the ongoing

monitoring of sanctions and grievances filed against health care professionals

• Ongoing monitoring of:– Lists of practitioners who have been sanctioned – Opt-out list– Beneficiary grievances– Sanctions and limitations on licensure on a regular basis between

recredentialing cycles• MAO is required to ensure that all credentialing requirements are

current at the time of initial credentialing and/or recredentialing, but is not required to monitor and account for any expiration dates on a continuous basis unless required to do so by the state


MAO – Recredentialing Process

• At least every 3 years• Updates information obtained in initial credentialing• Includes an attestation of the correctness and

completeness of new information• Considers performance indicators such as those collected

through– QAPI program– Utilization management system– Grievance system– Enrollee satisfaction surveys– Other activities of the MAO


MAO – Recredentialing Process

• Licensure must be re-verified from primary sources• Board certification must be re-verified only if the provider

was due to be recertified or states that he/she has become board certified since the last time he/she was credentialed or recredentialed

• National Practitioner Data Bank• Sanction or restriction information from licensing agencies

and Medicare (OIG/Opt-out)• Admitting privileges (attestation ok)• Malpractice coverage (carrier/face sheet/attestation)• DEA/CDS certificate (NTIS/CDS agency/copy


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Understanding CMS Requirements for Credentialing, Recredentialing, and Privileging in Hospitals and...

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