Credentialing & Privileging | 02.24.20
NAMSS President Attends National Credentialing Forum
by Roxanne Chamberlain, MBA, FACHE, FMSP, CPMSM, CPCS, CPHQ
NAMSS President Roxanne Chamberlain, MBA, FACHE, FMSP, CPMSM, CPCS, CPHQ, attended the National Credentialing Forum (NCF) Feb. 7–8, 2020, in San Diego. Attended by the foremost experts in credentialing, the NCF brings together organizations and individuals interested in credentials verification for healthcare professionals for a day and a half conference to share information, provide networking opportunities, and develop strategies and initiatives to improve the credentials verification process in an informal setting. Below are the various topics covered during the Forum.
New NCQA Requirement
At NCF, the new NCQA requirement came into discussion and signified a stricter shift in credentialing. The new requirement includes the following:
CR 1C: Credentialing System Controls
The organization’s credentialing process describes:
- How primary source verification information is received, dated, and stored
- How modified information is tracked and dated from its initial verification
- Staff who are authorized to review, modify, and delete information and circumstances when modification or deletion is appropriate
- The security controls in place to protect the information from unauthorized modification.
- How the organization audits the processes and procedures in factors 1–4
Must Pass Requirements
CR 1C: Credentialing System Controls
CR 3A: CR Verification
CR 3 B: Verification of Sanctions
CR 3 C: Practitioner Application
CR 4A: Re-credentialing Cycle Length
Scoring and Accreditation Requirements
- Separated HEDIS CAHPS from accreditation
- Accreditation status
- Scoring changes
- Before — must meet 70% of the standard points
- Current — must meet 80% of the points for each category
- Scoring
- Before — 5 levels of scoring depending on the number of measures (factors)
- After — Met, Partially, Not Met
- Points
- Before — Different for each element
- After — 1 or 2
Not Reviewed at Renewal
- CR 1A and B: CR Description and Practitioner Rights
- CR 6A: Actions Against Practitioners
- CR 7A-C: P & Ps on Provider Assessment, still look at evidence of assessment
In summary, credentialing has become even more important, as you must get 80% of the points or higher in this area.
The Effect of Value-based Healthcare on the Organized Medical Staff — Credentialing, Privileging, Peer Review, and Quality
This topic, presented by Dr. Mark Smith, focused on system integration and regional delivery of care to match the patient with the best provider of care. Outcomes and cost are now measured for every patient. Smith also cited the need to modify credentialing and privileging to meet value = (quality x experience)/cost. Additionally, there is a need to automate mass data for abstraction, analytical processing, and reporting capabilities. Overall, timely and accurate data is a necessity.
More MDs are getting MBAs and other leadership/management education so they can work in the executive suite. There is greater dependence on using advanced practitioners now. Subspecialization and cross-over areas are a real challenge. Initial competency (Focused Professional Practice Evaluation) is more problematic due to increased specialization and decreased experience in training.
Accreditors
For the Healthcare Facilities Accreditation Program (HFAP), there are no new credentialing and privileging standards. They have been citing healthcare organizations, because their data is not telling them how their providers are doing in relation to being competent. They do not want numbers (i.e., how many admissions a provider had) but rather meaningful analyzed data. They also are surveying ways to determine what competencies are needed for each subspecialty in relation to privileges.
In addition, they are looking to see if the medical staff is reviewing and updating the bylaws and that they are involved in the credentialing process. They also are citing the human resources orientation for physicians when there is no objective evidence this occurred, and also because orientation annual education is not occurring.
2020 Legal Update
Brian Betner, JD, reviewed two legal trends that continue: “Erosion of the Peer Review Privilege” and “Professional Liability and Accountability Including Fraud and Abuse.”
He discussed industry stress factors that seem to be accelerating, which include market disruptors, technology, and higher standards/less tolerance for deviation. There continues to be election drama and false promises in relation to healthcare. Proposals range from Medicare for all to a complete rollback of ACA consumer protections and replaced with free market principles through federally funded state high risk pools. The real issue is more about the healthcare industry adapting to the existing legal framework. Now, if something goes wrong with care provided in a hospital by a doctor, that hospital will be compared to other hospitals in the marketplace which is now replacing negligent credentialing as the malpractice claim.
Physician Assistant Update
Tricia Marriot, PA-C, MPAS, said we are seeing more state laws changing in relation to physician assistants in addition to the elimination of chart reviews and collaborative agreements.
Greg Thomas, PA-C, representing the NCCPA, noted that nearly 10,000 PAs become certified per year. The primary specialty of a PA is family medicine at 23.9%, surgery specialties at 21.49%, and the medial age of a PA is 38. Since 1980, when only 36% of PAs were female, now 68.8% of PAs are female identifying. For the primary practice setting, hospitals account for 40.5%, office-based private practice is at 39.5%, and federal government facilities is at 5.5%.
As it currently stands, PAs need 100 CME credits every two years, and 50 of them must be Category I credits. In order to recertify, PAs must take the exam every 10 years. There currently is a pilot design occurring which equals the longitudinal assessment of core medical knowledge (assessment for learning). During each quarter, the PA must answer questions over time, but this can be done from any device and from any location to make it easier for them to do. There are more than 1,850 PAs signed up for this pilot.
FSMB Update
Ms. Jama Ball discussed the licensure uniform application being using in some states for advanced practitioners. The only information the FSMB verifies is training information. They also produce an annual physician census. To make it simple, they only ask physicians for data that the FSMB does not already have. They have moved to digital credentialing and collect information from hospitals who have closed electronically, and they use a lifetime medical education service to house digital documents.
Blockchain and Payer Credentialing
Ms. Rachelle Silva discussed a pilot blockchain initiative by Synaptic Health Care Alliance to see what can make the process of keeping provider directories up to date and accurate. This provider data exchange is a permissioned-only blockchain, so you would need to become a member to have access to it. Quorum is the fastest blockchain technology, and that is who this alliance is using. This will be test piloted in a few state markets.
There also was a general discussion about the ability of blockchain technology to be hacked. It was noted that it is an exchange of information and is not centralized, so it can’t be hacked without seeing who was trying to change the blockchain data. As specified by Silva, the data is not proprietary, and the blockchain is auditable.
ABMS Task Force Update
Ms. Jennifer Michael from the ABMS provided a task force update. ABMS is working to establish consistent definitions/terminology related to reentry for board certification. The standards task force will develop a first draft of revised standards by February 2020, revised set by June 2020, and then a final draft to be presented to the ABMS Board in October 2020. However, before the final draft is presented, there will be a review for public comment.
AOA Update
Ms. Kathleen Creason stated that on the Osteopathic Continuing Certification (OCC) on the AOA profile will state if a provider is not meeting the OCC requirements. Early entry certification will be open to certain DOs and MDs who meet the eligibility requirements (specifically family medicine and internal medicine). There is now an addiction medicine sub-specialty board certification available.
American Academy of NPs (Certifying Board)
Rick Meadows, APN, said 21,500 NP board certification exams were completed with an overall pass rate of 85%. He noted that the Doctor of Nursing degree (DNP) can be in administration or other areas with the chance that the candidate might not become a nurse practitioner. There is now a new nurse practitioner board certification in emergency medicine/urgent care. There are about 400 NP programs in the U.S.
Telemedicine — Documentation Required, Desired, and Unnecessary for Credentialing
Ms. Geneva Harris, CPCS, CPMSM, and Ms. Vicky Searcy gave an overview of credentialing telehealth providers. Only 12% are using credentialing by proxy, only 46% use a combination (they do some credentialing by proxy as well as full credentialing), and 42% fully credential telehealth providers. It was noted that the state of Massachusetts is the only state that does not allow credentialing by proxy.
They both went over documentation requirements by CMS and TJC. They also noted the only orientation needed is on how to use the equipment. In addition, no flu shot is needed, as they are not entering your facility.
AMA Update
Ms. Tammy Weaver talked about physicians and MSPs regarding the credentialing process. The physicians complain they send their applications into the medical staff office and often do not hear anything for quite some time. They prefer more frequent communication from the MSO. MSPs biggest complaint about physicians is not receiving complete applications.
The AMA is planning to do a “boot camp” regarding credentialing in June 2020 on social media. They also plan to develop a physician leadership academy. The AMA also hired a Chief Equity Officer regarding diversity and inclusion.
NPDB Update
Mr. David Lowenstein stated that 9.3 million queries were processed in 2019. Twelve percent of those queries found something in the NPDB. The NPDB has been working on algorithms to ensure accuracy. They also started a webcast series. They are now looking to update the guidebook again, but there will be no significant changes.
Microhospitals
Ms. Janet Wilson gave an update about how her organization built four microhospitals, as it is less of a burden building them financially. They are using them to fill a gap in care. These four microhospitals have a unified medical staff. Some of these hospitals only have 3–4 physicians, so it helps to have a unified medical staff if one of the providers is out. They also have one credentials committee and one medical staff executive committee for these microhospitals. Each hospital has around 8–15 patient beds. They do not usually place these hospitals in rural areas, as they need to be part of a system because they are so small.
In conclusion, the NCF proved beneficial for the countless credentialing experts who attended. The future is looking bright for improvements in credentials verification.
Roxanne Chamberlain, MBA, FACHE, FMSP, CPMSM, CPCS, CPHQ, is the senior director of medical staff services at Baystate Health System in Springfield, Massachusetts and is the current NAMSS President.