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What They Don’t Teach You in Medical School

What They Don’t Teach You in Medical School. (Steps in Medical Staff Credentialing) March 13, 2008 Judi Smedra, CPMSM, CPCS Director, Medical Staff Affairs The University of Kansas Hospital. CREDENTIALING .

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What They Don’t Teach You in Medical School

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  1. What They Don’t Teach You in Medical School (Steps in Medical Staff Credentialing) March 13, 2008 Judi Smedra, CPMSM, CPCS Director, Medical Staff Affairs The University of Kansas Hospital

  2. CREDENTIALING • Process of obtaining, verifying, and assessing the qualifications of a healthcare practitioner to provide patient care services in or for a healthcare organization

  3. WHO’S WATCHING YOU NOW? • The Joint Commission (H) • National Practitioner Data Bank (H) • Managed Care Organizations (H) • Hospital Boards (Ultimate Authority) (H) • CMS (Medicare) • Medicare/Medicaid StateProfessional Review Organizations • State Board Of Healing Arts • Managed Care Accrediting Agencies (M) • Credentials Committee (Final Decision) (M)

  4. WHAT ARE THEY LOOKING FOR? • Quality Patient Care • Efficient Patient Care • Length Of Hospitalization • Legible Charts • Medical Records Compliance • Citizenship (H) • Privileges Requested MatchPrivileges Performed (H) • Continuing Medical Education (CME)Pertains To Specialty (H)

  5. APPLICATION PROCESS – WHAT TO EXPECT • Group Practice Dictates Where You Practice & How to Obtain Application • Be Complete & Accurate • Privileges / Membership Will Not Be Granted Overnight! • Expect Application Fee and/or Dues

  6. APPLICATION PROCESS – MAKE IT EASY ON YOURSELF! • Account for All Time Periods – Month & Year (must document gaps > 30 days) • Training • Affiliations / Work History • Insurance Carriers • State Licenses

  7. APPLICATION PROCESS – MAKE IT EASY ON YOURSELF! (continued) • References (must be in your specialty) • Medicare/Medicaid Provider Numbers • NPI (National Provider Identifier) • Signed Attestation / Release (authorization)

  8. PRIVILEGES • Will Be Required To Produce Documentation Of Training And/Or Experience • Proctoring May Be Required For Specified Time Period Or Number Of Procedures

  9. DOCUMENTATION CHALLENGES • Curriculum VitaeDates (include Month & Year)Identify Custodian of Records for Closed Training Programs/Affiliations • LicensureKansas – Postgraduate LicenseMissouri – Temporary License for Training • Diplomas / CertificatesMedical School, Training Programs, Boards

  10. DOCUMENTATION CHALLENGES(Continued) • DEA CertificatePrescribe/Administration of DrugsKansas/Missouri • BNDD • Change of Address • Case Log • Photograph For Identity • Compliance Training/Exams (HIPAA,Privileges)

  11. PRIMARY SOURCE VERIFICATION • Direct Contact With Sources To Guarantee That Statements Are Legitimate, Unchallenged & Appropriate

  12. TYPICAL VERIFICATION • Completed Application - All Activity from Medical School to Present • AMA OR AOA Profile • Verification Of All Licensure • Training & Competency • Board Certification • ECFMG (If Applicable) • Criminal Background Check • Malpractice Claims History

  13. TYPICAL VERIFICATION(Continued) • Group Practice Affiliations • NPDB Report (H) – HIPDB Report (M) • Peer References • Office Of The Inspector General • General Services Administration • Timeframe • Burden Of Proof Is On You!

  14. REAPPOINTMENT • Provisional / Probationary (H) • Joint Commission – Every Two Years (H) • NCQA (Managed Care Organizations) – Every Three Years (M)

  15. MEDICAL STAFF COORDINATOR Your Best Friend or Worst Nightmare – Your Choice!

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