credentialing and privileging ahps - memberize

Credentialing & Privileging AHP and CAM

© Kathy Matzka, CPMSM, CPCS, LLC www.kathymatzka.com 1

CREDENTIALING

and PRIVILEGING

AHPS and CAM

CREDENTIALING

and PRIVILEGING

AHPS and CAM

Kathy Matzka, CPMSM, CPCS

2

3



4

5

6



7

8

9



10

WHY AHPs?• “Physician Extenders”

• Paid approximately half of a new physician’s salary

• Generate substantial revenue

• Economic factors and physician shortages in rural and underserved areas

11

Categories of Advanced Practice

Nurses (APNs)• Nurse practitioners (NP)

– Deliver front-line primary and acute care in community clinics, schools, hospitals, and other settings

– Perform such services as diagnosing and treating common acute illnesses and injuries, providing immunizations, conducting physical exams, and managing high blood pressure, diabetes, and other chronic problems

• Certified nurse-midwives (CNM)

– Provide prenatal and gynecological care to normal healthy women

– Deliver babies in hospitals, private homes, and birthing centers

– Follow-up postpartum care

• Clinical nurse specialists (CNS)

– Provide care in a range of specialty areas (cardiac, oncology, neonatal, pediatric, OB/GYN, etc.)

• Certified registered nurse anesthetists (CRNA)

– Administer more than 65 percent of all anesthetics given to patients each year

– Sole providers of anesthesia in approximately one-third of U.S. hospitals

Source : American Association of Colleges of Nursing

12



Medical Staff Organization

• May have a separate AHP Staff functioning

under the medical staff

• May include a special multidisciplinary

committee (Medical Staff, Nursing, HR,

Administration)

13

Hospital - Who Gets Privileges?

• Licensed Independent Practitioners

– APNs

• Those performing “surgical tasks”

– Surgical PA, RNFA

• Other medical professionals who perform

medical services independently

14

NCQA CR 1 – Credentialing

• Practitioners licensed, certified or registered by the state to practice independently (without direction or supervision)

• Practitioners with independent relationship with the organization– Independent relationship = organization directs its

members to see a specific practitioner or group of practitioners

– Includes all primary care practitioners

• Practitioners who provide care under the organization's medical benefits

15



NCQA AHP Examples – CR 1

• Chiropractors

• Nurse practitioners

• Addiction medicine specialists

• Doctoral or master’s-level psychologists.

• Master’s-level clinical social workers.

• Master’s-level clinical nurse specialists or psychiatric nurse practitioners.

• Other medical practitioners or behavioral healthcare specialists

16

Dependent AHP

• Employee of a medical staff appointee

• Works under the supervision of physician employer

• Sees only patients of that physician employer or his/her partners

• State law may require a collaborative practice agreement

• May or may not have state license

• Contracted by organization

17

Determining if Independent or

Dependent

• Scope of license, certification, (State regs)

• Function in specific setting

• What Treatment/Services/Care Services will be provided?

• Will the AHP

– take call or cover for physician on call

– make independent decisions

– practice with or without supervision

– need co-signature on records

18



CMS REGULATIONS AND

INTERPRETATIVE GUIDELINES

19

CMS Hospital CoPs

• All Interpretative guidelines and manuals are on website

– Rev. Rev. 116, 09-26-14 - 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

20

Surgical Services §482.51(a)(4)

• Surgical privileges must be delineated for all

practitioners performing surgery in

accordance with the competencies of each

practitioner

21



Interpretive Guidelines §482.51(a)(4)

If the hospital utilizes RN First Assistants, surgical PA, or

other non-MD/DO surgical assistants, the hospital must

establish criteria, qualifications and a credentialing

process to grant specific privileges to individual

practitioners based on each individual practitioner’s

compliance with the privileging/credentialing criteria

and in accordance with Federal and State laws and

regulations. This would include surgical services tasks

conducted by these practitioners while under the

supervision of an MD/DO.

22

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…

23

Medicare Conditions of Participation

Hospital and CAH

• CoPs require criteria for determining privileges

and for applying the criteria:

– Individual character

– Individual competence

– Individual training

– Individual experience

– Individual judgment

24



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.

25

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

26

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

27



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.

28

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

29

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

30



JOINT COMMISSION

31

TJC Standards

• APRNs and PAs who provide a “medical

level of care”– credentialed and

privileged through MS only (See 2011

BoosterPak©)

• Medical level of care= making

independent diagnosis and treatment

decisions

32

TJC Standard HR.01.02.05

• PAs and APRNs not providing a “medical level of care” cred/priv through MS or equivalent process approved by Board

• An equivalent process:

– Evaluates credentials/current competence

– Includes peer recommendations

– Involves communication and input among individuals and committees, including MEC, in order to make an informed decision regarding the applicant’s request for privileges

33




• Hospital confirms that non-employees brought in by an LIP to provide care, treatment, or services have the same qualifications and competencies required of employed individuals performing the same or similar services at the hospital

• LIP employer can assist with confirmation

• If not currently performed by anyone employed by the hospital, it is leadership consults appropriate professional organization guidelines with respect to expectations for credentials and competence.

34


• When LIP brings a non-employee in to provide

care, treatment, and services, hospital reviews

the competencies and performance at the

same frequency as individuals employed by

the hospital

• LIP employer can help

35

Reappointment/Reassessment

• Joint Commission – FPPE/OPPE

• CMS – §482.51(a)(4) - Surgical privileges - MS appraisal

procedures must evaluate each individual practitioner’s

training, education, experience, and demonstrated

competence as established by the QAPI program,

credentialing process, the practitioner’s adherence to

hospital P&P, and in accordance with scope of practice

and other State laws and regulations

• Verify Licensure, relevant training or experience, current

competence, and ability to perform the privileges

requested

36



Sample HR “Equivalent” Procedure

• Credentials Verification

• Department Manager/Physician Director

Review

• Credentials Committee/MEC Review/Input

• Approval by Board

37

Employed Practitioners

• Both MS and HR standards apply

• Need to coordinate process between HR and

MS

38

Medical Staff Privileges

• Privileges are granted within area of practice - they are not a right

• Applicant/employer must prove qualifications through documentation of training and/or experience

• Hospital governing body decides who will practice at facility and what they will be able to do

39



Delineating Privileges

• Check state licensure board/scope of practice– Collaborative agreement

– Supervision requirements

• Ask employer what this person will do

• Ask AHP what they want to do (Is this the same as what the physician employer wants?)

• Check certifying agency

• Confer with Nursing Administration

• Check standard of care in community (network with colleagues)

• Avoid listing routine nursing duties for APNs

• Check job description for employees

40

NPDB Requirements• Hospitals must query when physicians, dentists, and

other health care practitioners apply for medical staff appointment or for clinical privileges, and every two years on physicians, dentists, and other health care practitioners who are part of the medical staff or who hold privileges

• Must report physicians and dentist, may report other practitioners

• Other health care practitioners are defined as individuals other than physicians or dentists who are licensed or otherwise authorized (certified or registered) by a State to provide health care services

Source - NPDB Guidebook

41

Negative Recommendation

• Appeals mechanism

• May not be same as for MS member

• Need to determine hearing rights for facility -

employed AHPs

– employee grievance process and/or

– Medical Staff process

• State law may define

42



WHY CHECK OIG?

“The effect of an OIG exclusion from Federal health care programs is that no Federal health care program payment may be made for any items or services (1) furnished by an excluded individual or entity, or (2) directed or prescribed by an excluded physician (42 CFR 1001.1901).”

OIG Special Advisory Bulletin, September 1999

• http://oig.hhs.gov/fraud/docs/alertsandbulletins/effected.htm

43

Complimentary

and Alternative

Medicine

44

Complimentary and Alternative

Medicine

• Complementary medicine is used together

with conventional medicine

• Alternative medicine is used in place of

conventional medicine

• Integrative medicine combines mainstream

medical therapies and CAM therapies

45



National Center for CAM

• MAJOR TYPES OF CAM

• Alternative Medical Systems - Traditional Chinese, Native

American, Homeopathy

• Mind-Body Interventions - Journaling, Imagery, Meditation,

Hypnosis)

• Biologically Based Therapies - Aromatherapy, Herbal

Preparations

• Manipulative and Body-Based Methods - Massage, Tai Chi,

Yoga, Dance Therapy

• Energy Therapies - Healing/Therapeutic Touch, Reiki

(Japanese technique for relaxation and healing)

Source: nccam.nih.gov46

47Source: National Center for CAM – 2011-2015 Strategic Plan – NIH, US

Department of Health and Human Services

48

Source: National Center for CAM – 2011-2015 Strategic Plan – NIH, US

Department of Health and Human Services



Challenge: Integrating evidence-based,

cost-effective CAM into the HC system

“Physicians, indeed all health-care

professionals, have a duty not only to

avoid harm but also a positive duty to do

good— that is, to act in the patient’s best

interest[s].”

Model Guidelines for the Use of Complementary and

Alternative Therapies in Medical Practice – FSMB

http://www.fsmb.org/pdf/2002_grpol_complementary_alte

rnative_therapies.pdf

49

Things to Consider

• Professional organizations have different

requirements for education, scope of practice,

continuing education requirements, etc.

• Licensing requirements vary

• Scope of practice varies

50

Things to Consider

• Community need

• Hospital ability to accommodate

• How to Evaluate

• Acceptance by Patients/Staff

51



Steps To Take Before Adding New

Categories of Providers

• State regulations

• Hospital’s mission statement

• Review/Revision of Medical Staff Bylaws/ R&R/Policies

• Consult With Nursing/HR/HIS/IS/MSEC

• Evaluate Additional Resources Needed

• Development of Guidelines/Protocols

– Medical staff and Nursing

• Additional Staffing/Additional Equipment

52

Questions?

53

[email protected]

credentialing and privileging ahps - memberize

Documents