Friday, June 30, 2017

Top Five Changes in Credentialing Due to the Increased Numbers of Employed Practitioners in Healthcare Organizations

Guest post by Vicki L. Searcy. Vicki is  Vice President, Client Success Services and Consulting for Morrisey, and Echo. 

All of us who work in healthcare have seen and experienced the many changes that have occurred as a result of the shift of organizations to increasingly employ/contract with practitioners. It is not unusual for an organization to employ/contract with 50% or more of their practitioners. The numbers keep rising and it doesn’t appear that there is a downturn in this trend any time soon.

What impact has this had on the individuals who work in credentialing (and provider enrollment)? Here are the top 5 impacts that I’ve observed:

1. The need to successfully integrate the recruitment/credentialing/enrollment process (i.e., the onboarding) has become acute.

Organizations that want to streamline their onboarding processes must determine processes that can occur concurrently rather than consecutively. There must be a defined time during the recruitment phase/contracting when information is made available to the credentialing department so that the credentialing/privileging process can begin. Each organization also needs to determine when enrollment activities can begin so that when a practitioner is credentialed, there is no big lag time between the credentialing approval date and the date on which services can begin to be provided to patients. This sounds easy – but it obviously isn’t.

Tackling these processes – and determining what can be done concurrently versus what must be completed prior to the next process beginning takes a lot of discussion, willingness to change, some willingness to give up some control and a huge dose of cooperation. However, organizations that have successfully transformed their onboarding process have found it to be well worth the time and effort that it took to get there because of increased practitioner satisfaction and increased revenue.

2. As the numbers of employed/contracted practitioners increase, there are more practitioners for whom enrollment with health plans must be managed.  Additionally, there is also a trend for organizations that employ/contract with practitioners to also manage their credentialing process with organizations outside of the health system.

This item is pretty obvious – as the number of employed/contracted practitioners increases, so will the numbers that need to be enrolled with payers. Additionally, I’m seeing that many of these enrollment or “credentialing” departments are also responsible for facilitating the credentialing process for hospitals/facilities that are not part of the healthcare system. For example, let’s say that we have a group of practitioners that needs to be credentialed at a hospital in the geographic area that is not within the system. Perhaps the hospital provides a service that is not provided by the healthcare system or takes care of specific types of patients. The employed/contracted physicians must be credentialed by the hospital and the “credentialing” department of the health system obtains, facilitates completion of and sends applications, documents, etc. to the hospital so that the physicians can be credentialed there. This adds an additional layer of complexity to the work that someone or some department is providing.

3. Proliferation of files – there is now a big need to clearly identify what information is located in the credentials file vs. the “HR” file.

This is an issue that needs to be tackled by many health systems. I see much duplication between documentation and data collected by the Human Resources department and credentialing. There is usually no need to duplicate documentation in the HR file. This is an issue that can and should be tackled when the onboarding process is analyzed. It will usually require some advice from legal counsel about what goes where. HR files should not contain “peer review” documents – those should be contained in the credentials file. There is no need for both departments to verify licensure, etc. Elimination of duplication of activities will help streamline the onboarding process and will also protect information that should not be discoverable in legal proceedings.

4. There is a need for credentialing departments to find out what a practitioner has been hired to do – because of the impact on the privileges that should/should not be requested.

It is becoming fairly routine in some organizations to provide a privilege delineation to an employed/contracted practitioner – only to return it to him/her and ask that it be resubmitted because the practitioner asked for privileges not covered by the contract or – conversely – didn’t ask for privileges that he/she is expected to provide. This often does not occur until the decision-making process when the privilege delineation is reviewed by someone who is responsible for the services that the applicant will be providing once credentialed – an awkward situation at best that requires rework and can add length to the credentialing process. Organizations need to provide better guidance to the practitioners who are asked to complete privilege delineations or have a process in place to have someone review them immediately upon submission.

5. Finally, employed physicians are likely to work in multiple organizations within a health system. There is a trend within health systems to standardize privileges across the system to help more easily facilitate the ability for practitioners to provide services across the organization.

Standardizing privileges within a health system used to be something that CMO’s and others from the C-suite would talk about wistfully. I’ve had many conversations about this with CMO’s who indicated that they were not willing to expend their political capital on something (like standardizing privileges) that they did not believe could or would be successful. The word is out, however, that this can be successfully achieved and more and more organizations are initiating privileging standardization projects. Is it easy? Not usually – but there are tremendous benefits for organizations that persevere.

We can be certain that credentialing and privileging will continue to evolve and that there will be new and constant challenges that those of us who work in this field will need to tackle. The challenges are one of the reasons why I’m never bored!

To hear more on this topic tune in to our latest webinar.

Friday, June 23, 2017

The War Over Maintenance of Certification Heats Up

Excerpts from Medscape Article  published June 23, 2017

The Growing Anti-MOC Movement

Although many things make doctors angry, only one issue has made them angry enough to join together in a unified effort to demand relief from their medical societies and representatives in state legislatures: mandatory maintenance of certification (MOC), particularly for hospital credentialing and insurance network membership.

Pressing state lawmakers to enact anti-MOC legislation has become a cause célèbre for disparate grassroots doctor organizations that have sprung up from Florida to California. Among them are the National Board of Physicians and Surgeons (NBPAS), American Association of Physicians and Surgeons (AAPS), Practicing Physicians of America (PPA), and the Association of Independent Doctors (AID).

"We have amassed almost 50,000 physicians who are communicating about this on Facebook," claims Westby Fisher, MD, director of cardiac electrophysiology at NorthShore University Health System in Evanston, Illinois. Dr Fisher is a co-founder and treasurer of PPA. Formed this year, PPA is a coalition of grassroots physician groups.

Forces have coalesced into a movement that has been influential in spurring medical societies to propose legislation to ban mandatory MOC requirements by hospitals and insurers in at least 17 states this year.

Formidable MOC Proponents

Seeking to block anti-MOC legislation, say movement leaders, are the American Board of Medical Specialties (ABMS), which sets the standards for physician certification in partnership with 34 member boards, and some hospitals and health insurers operating in a given state.

These pro-MOC forces have mounted lobbying campaigns to convince state legislators that hospitals requiring MOC for physician credentialing and insurers requiring MOC for physician reimbursement and network participation should be permitted to continue in the interest of quality of care and patient safety, say physician-legislators who have sponsored anti-MOC legislation.

"It's a David vs Goliath battle," Dr Fisher says.

But doctors in the anti-MOC movement charge that whereas initial board certification is a legitimate requirement, MOC has evolved into a money-making scheme that forces them to pay re-certification testing fees that are too costly and are required too often.

ABMS has tried to meet the doctors halfway. ABMS Member Boards have adopted several changes that lower the costs, increase the relevance of the process to practice, increase flexibility for meeting the standards, and make the whole process more convenient.

Among the changes ABMS cites are remote proctoring or online assessment and other innovations that eliminate the expense and time cost of the exam; the use of resources to simulate the way physicians practice at the bedside; new testing approaches that are more customized to practice and more formative, to help doctors focus their learning; a focus on clinical judgment and decision-making rather than recall of medical facts; and more convenient access to practice-relevant learning and improvement activities.

However, none of these attempts at appeasement, or anything short of making MOC non-mandatory, is stopping doctors in the anti-MOC movement from seeking legislative relief.

Read more on how individual states are handling this anti-MOC movement.

6 Ways to Quash Privileging Squabbles Among Clinical Staff

This article was originally published on Credentialing Resource Center Daily, June 19, 2017.

The number of privileging disputes occurring in hospitals is growing rapidly. It’s easy to understand why if you examine how medicine has evolved. In the “good old days,” physicians of all specialties had a defined area of turf on the playing field and specialties didn’t cross those boundaries.

Now things are different.

The acrimony that can arise from such disputes often leaves scars and wounds on medical staffs that may not be prepared to deal with the change and conflict associated with this challenge.

The following steps will help your medical staff as it deals with challenges to conventional privileging:

1. Assign responsibility for dispute resolution to a small, very experienced committee. Ideally, the credentials committee or perhaps a medical staff standards committee must be charged with the responsibility of "owning" resolution of all privilege disputes.

2. Research, research, research any and all matters or disputes concerning the granting of clinical privileges. Assign a staff person to research and prepare a full background paper concerning the issue at hand. This step is absolutely critical to effective dispute resolution due to the fact that the committee needs unbiased, objective information concerning the issue in order to dialogue effectively with parties to the dispute.

3. Involve the disputing parties. At the conclusion of the research period, a member of the credentials committee should facilitate a discussion between or among the involved parties in an attempt to solicit a consensus recommendation concerning the amount of education, training and experience necessary for the safe and effective performance of the procedure in question.

If the involved parties decline the invitation to meet, then each party should be requested to advise the credentials committee, based upon their own knowledge and with reference to the research concerning the amount of education, training, and experience they believe is necessary to perform the procedure safely and effectively.

A firm time period should be identified for receipt of their recommendation.

4. Have the credentials committee review recommendations. If a consensus was reached, the job of the credentials committee is to test the consensus recommendation against the following criteria:

  • If a physician with this amount of education, training, and experience were granted privileges at this facility, would we be comfortable referring a friend to the practitioner?
  • If the answer to this question is yes, the credentials committee should proceed to recommend adoption of the rule.
  • If the answer is no, the credentials committee's job is to craft a rule, based upon review of the research and after consideration of the various recommendations that will, in their opinion, serve to ensure safe and effective provision of patient care.
  • It may be necessary to touch base once again with the disputing parties and request that they document their objections to a proposed rule in formal minority reports that can be considered at a later point in the process.

5. Consider the proposed rule by the medical executive committee with subsequent recommendation (if controversial) to the board of directors. It is absolutely vital at this point that the policies and procedures used by the credentials and executive committees preclude procrastination, end runs, serious consideration of "threats," or departmental filibusters.

If such activities are tolerated, it is likely that the dispute will escalate into a battle, if not a war.

6. Codify each of the above steps into a formal policy. This procedure should be used during the development of standards for granting and re-granting of clinical privileges.

Such a policy should be recommended by the credentials committee, executive committee, and approved by the board. Once approved by the board, it should be followed absolutely in the resolution of any dispute concerning the granting of clinical privileges.

For more information on establishing and implementing clinical privileging , contact us today.

Friday, June 16, 2017

Provider Data Action Alliance Starts Work on Roadmap to Improve Accuracy of Healthcare Provider Data

Excerpts from Council for Affordable Quality Healthcare (CAQH) press release.

A cross-section of healthcare leaders has begun work on a wide-ranging effort to improve the accuracy of provider data for both industry stakeholders and patients. Convened by the non-profit alliance CAQH, the Provider Data Action Alliance will develop a roadmap that articulates a vision and actionable strategies for obtaining and sharing better information. Alliance participants represent health, dental and vision plans; provider organizations; health systems; government; and health information exchanges.

Despite the considerable investment by the healthcare industry to attain and manage that data—currently estimated at more than $2 billion annually—inaccurate information is common. For example, a report released earlier this year by the Centers for Medicare & Medicaid Services (CMS) found that 45.1 percent of practice locations listed in on-line provider directories were incorrect.

Alliance participants will develop strategies to address the challenges of ensuring accurate and timely provider information. These include managing data that changes frequently due to practice location moves, retirement or other life events. In most cases, providers must inform a number of health plans and healthcare organizations of each change, a redundant process that adds to the administrative burden for providers. Requirements for data collection vary depending on the stakeholder and state regulations. The need to increase provider engagement in the maintenance process is another key issue and focus of the Alliance.

The Alliance was a result of the 2016 Provider Data Summit, a CAQH-hosted conference where more than 100 industry leaders met to discuss provider data challenges. Attendees reached agreement on the priorities for improving provider data and called for further industry-wide collaboration.

Learn more about the Provider Data Action Alliance at

Thursday, June 15, 2017

Cross-State Licensing Process Now Live in 8 States

Excerpts in this post originally appeared in AMA wire.

The Interstate Medical Licensure Compact (IMLC), an initiative designed to expedite state medical licensure for physicians who wish to practice in multiple states, is now live and accepting applications. Currently, eight of the 19 states in the compact can act as the primary state of licensure and source of verification through the compact. These are Alabama, Idaho, Iowa, Kansas, Mississippi, West Virginia, Wisconsin and Wyoming. Ten states—Arizona, Colorado, Illinois, Minnesota, Nebraska, New Hampshire, Nevada, Pennsylvania, South Dakota and Utah—are still preparing to accept applications for verification and background checks but currently cannot act as the state of principal licensure.

The IMLC will make it easier for experienced physicians with positive practice histories to apply and receive licenses in states they’re not currently licensed in. The IMLC estimates that 80 percent of physicians meet the interstate licensure criteria.

  • The compact is a contract between states designed to promote cooperation and adaptation among states. It operates on several key principles:
  • The practice of medicine is defined as taking place where the patient receives care, meaning that the physician must be licensed in that state and under the jurisdiction of that state’s medical board.
  • The commission, made up of representatives from each adopting state, will enforce rules made to expedite the licensing process. Participating state medical boards will retain regulatory authority.
  • All participation is voluntary for both physicians and states.

The IMLC ensures that the language of the compact is identical in all states that have joined. This will not only make the process more efficient for physicians, but will also help ensure that uniform safety measures are met across states.

In addition to modernizing the licensing process, organizations such as the AMA that support the IMLC hope that making it easier for physicians to practice across state lines will increase access to care for patients in underserved areas.

What does this mean for provider credentialing?

The primary areas this new initiative affects are primary source verification and sanctions monitoring. To ensure that you are properly monitoring current licenses and any sanctions or disciplinary actions, you will need to check not only the current state your facility resides in and where the provider is practicing, but also have a process in place to check across state lines.

Your process should offer real time verification and monitoring rather than waiting weeks or months to have your provider data updated, and you should make sure that you are collecting all relevant state data.

Contact Us to discuss your primary source verification and sanctions monitoring processes to see if you need to upgrade.