What They Don t Teach You in Medical School

1. 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. 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. 3 You can read the book �Blind Eye� by James Stewart which details the career of Dr. Michael Swango starting with his medical schooling in Ohio and ending with his arrest after allegedly killing over 35 patients in the United States and Zimbabwe. This is an example of residency training not being properly verified and of the �Good Ole Boy� network that, hopefully, is being destroyed. Megaffin � This is an example of even if we do our job correctly, sometimes behavior will happen after the doctor is on staff that requires discipline and in his case � loss of license and being sent to prison.You can read the book �Blind Eye� by James Stewart which details the career of Dr. Michael Swango starting with his medical schooling in Ohio and ending with his arrest after allegedly killing over 35 patients in the United States and Zimbabwe. This is an example of residency training not being properly verified and of the �Good Ole Boy� network that, hopefully, is being destroyed. Megaffin � This is an example of even if we do our job correctly, sometimes behavior will happen after the doctor is on staff that requires discipline and in his case � loss of license and being sent to prison.

4. 4 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) It has been estimated that approximately 3 � 7 % of physicians in this country provide substandard patient care or have behavioral issues, criminal histories, or health issues (including substance abuse) that could adversely affect patient care. Hospitals and medical staffs have a responsibility to the patients to do everything possible to ensure that the physicians providing that care are sufficiently trained, experienced, and competent to provide the best care possible. The Medical Profession answers to a wide variety of regulatory agencies. It has been estimated that approximately 3 � 7 % of physicians in this country provide substandard patient care or have behavioral issues, criminal histories, or health issues (including substance abuse) that could adversely affect patient care. Hospitals and medical staffs have a responsibility to the patients to do everything possible to ensure that the physicians providing that care are sufficiently trained, experienced, and competent to provide the best care possible. The Medical Profession answers to a wide variety of regulatory agencies.

5. 5 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) Length of Stay � One critical patient with long stay can make the difference between profit or loss at small hospitals. Legible charts � patient care compromised and physicians have been sued because of misinterpretation of orders. Medical Records Compliance: Verbal orders � check your state requirements. In Kansas � 72 hours/Missouri 48 hours (However CMS requires 48 hours) Do not use abbreviations Post op dictation requirements Utilization Review Committees will be reviewing care Citizenship � refers to demeanor, disruptive behavior, how you relate to others. You can be disciplined for disruptive behavior.Length of Stay � One critical patient with long stay can make the difference between profit or loss at small hospitals. Legible charts � patient care compromised and physicians have been sued because of misinterpretation of orders. Medical Records Compliance: Verbal orders � check your state requirements. In Kansas � 72 hours/Missouri 48 hours (However CMS requires 48 hours) Do not use abbreviations Post op dictation requirements Utilization Review Committees will be reviewing care Citizenship � refers to demeanor, disruptive behavior, how you relate to others. You can be disciplined for disruptive behavior.

6. 6 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 Good afternoon � I am here to explain the credentialing process, highlighting both similarities and differences. Requirements specific to Hospital applications are noted by (H); Managed Care application process are noted with (M). If there are no notations � requirements will be for both situations. I have worked in a 97 bed hospital in SE Kansas, 400+ bed in Wichita, a managed care organization in Kansas and now at an Academic Hospital. Each entity had their own specific bylaws and policies relating to credentialing, but the basic requirements are the same. If you join a group practice they will dictate where your practice and either obtain your applications for you or advise you who to contact. This process may entail completing a pre-application form also. Be complete and accurate Privileges will not be granted overnight - Processing time average is 45 - 60 days at a hospital setting. Application fees and/or dues can range from $150 to $1500. Good afternoon � I am here to explain the credentialing process, highlighting both similarities and differences. Requirements specific to Hospital applications are noted by (H); Managed Care application process are noted with (M). If there are no notations � requirements will be for both situations. I have worked in a 97 bed hospital in SE Kansas, 400+ bed in Wichita, a managed care organization in Kansas and now at an Academic Hospital. Each entity had their own specific bylaws and policies relating to credentialing, but the basic requirements are the same. If you join a group practice they will dictate where your practice and either obtain your applications for you or advise you who to contact. This process may entail completing a pre-application form also. Be complete and accurate Privileges will not be granted overnight - Processing time average is 45 - 60 days at a hospital setting. Application fees and/or dues can range from $150 to $1500.

7. 7 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 CV - Along with your application, you will receive instruction on how to complete, what documents are required to be submitted with the application, bylaws of the hospital and privilege form for your specialty with specific criteria which you must meet before you would be approved for the procedures. DOCUMENT FILE � ALL TRAINING CERTIFICATES, DIPLOMAS, LICENSES, MALPRACTICE INSURANCE CERTIFICATES, DEA, etc. Have easy-immediate access to information when you change locations. Gaps of time greater than 30 days must have an explanation, hence the need to document months and years. Affiliations � If associated with academic institutions note that �Faculty Appointments� are separate from �Medical Staff Appointments� and dates may vary. Be sure to include this information and the different dates of approval. Also need to include complete information on Moonlights and Locum Tenens (Not related to residency/fellowship training.) Insurance Carriers � Past 10 year history State License � copies of all (including non-renewed) CV - Along with your application, you will receive instruction on how to complete, what documents are required to be submitted with the application, bylaws of the hospital and privilege form for your specialty with specific criteria which you must meet before you would be approved for the procedures. DOCUMENT FILE � ALL TRAINING CERTIFICATES, DIPLOMAS, LICENSES, MALPRACTICE INSURANCE CERTIFICATES, DEA, etc. Have easy-immediate access to information when you change locations. Gaps of time greater than 30 days must have an explanation, hence the need to document months and years. Affiliations � If associated with academic institutions note that �Faculty Appointments� are separate from �Medical Staff Appointments� and dates may vary. Be sure to include this information and the different dates of approval. Also need to include complete information on Moonlights and Locum Tenens (Not related to residency/fellowship training.) Insurance Carriers � Past 10 year history State License � copies of all (including non-renewed)

8. 8 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) References � are not to be training directors as they will be required to address evaluations pertaining to the training program. Keep track of the Medicare/Medicaid number are you will be asked for that number when joining different practice groups�.document file. National Provider Identifier � (Page 21 � 24) � Will be mandatory May 23, 2007. (Residents will be required to apply for number so that can at minimum order discharge medications.) Signed attestation (that part of the document that you attest that all information included in the application is true, correct and complete to your best knowledge. Mistake many doctors make is to completely rely on the office staff to complete your applications. That office person cannot answer legal questions. Keep good records. References � are not to be training directors as they will be required to address evaluations pertaining to the training program. Keep track of the Medicare/Medicaid number are you will be asked for that number when joining different practice groups�.document file. National Provider Identifier � (Page 21 � 24) � Will be mandatory May 23, 2007. (Residents will be required to apply for number so that can at minimum order discharge medications.) Signed attestation (that part of the document that you attest that all information included in the application is true, correct and complete to your best knowledge. Mistake many doctors make is to completely rely on the office staff to complete your applications. That office person cannot answer legal questions. Keep good records.

9. 9 PRIVILEGES Will Be Required To Produce Documentation Of Training And/Or Experience Proctoring May Be Required For Specified Time Period Or Number Of Procedures More hospitals are developing core privileges for each specialty. Core is comprised of procedures that all residency programs throughout the USA are taught. Special procedures are those that require additional training over and above standard residency training programs. Hospitals may have established specific criteria that must be met before physician can request approval for that procedure. If you ask at initial appointment, training will be verified through training directors, affiliations, and references. Many hospital require proctors for stated period of time or number of cases. This is part of competency verification. Additional privileges requested after you have been appointed to the medical staff will require that you submit documentation of training and/or experience. This additional procedures may also require a �proctoring� period. CME requirements vary by State. Hospitals may also have specific requirements that your CMEs relate in part to your privileges, so should check that out. This information should be include in your application packet. More hospitals are developing core privileges for each specialty. Core is comprised of procedures that all residency programs throughout the USA are taught. Special procedures are those that require additional training over and above standard residency training programs. Hospitals may have established specific criteria that must be met before physician can request approval for that procedure. If you ask at initial appointment, training will be verified through training directors, affiliations, and references. Many hospital require proctors for stated period of time or number of cases. This is part of competency verification. Additional privileges requested after you have been appointed to the medical staff will require that you submit documentation of training and/or experience. This additional procedures may also require a �proctoring� period. CME requirements vary by State. Hospitals may also have specific requirements that your CMEs relate in part to your privileges, so should check that out. This information should be include in your application packet.

10. 10 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 CV � Months and Year Closed programs � identify custodians Training licenses must be converted to permanent licenses for Missouri and Kansas. Kansas applications require $300 fee which may be money order or cashier�s check. Request for application is on line. Once that request is completed, you will receive an application. Once completed application is received at the Kansas State Board, it will take 30-45 days to process request. In Missouri, you can download the application, complete and turn it in with supporting documentation and with $300 processing fee. They have a 60 day time limit to complete your application. CV � Months and Year Closed programs � identify custodians Training licenses must be converted to permanent licenses for Missouri and Kansas. Kansas applications require $300 fee which may be money order or cashier�s check. Request for application is on line. Once that request is completed, you will receive an application. Once completed application is received at the Kansas State Board, it will take 30-45 days to process request. In Missouri, you can download the application, complete and turn it in with supporting documentation and with $300 processing fee. They have a 60 day time limit to complete your application.

11. 11 DOCUMENTATION CHALLENGES(Continued) DEA CertificatePrescribe/Administration of DrugsKansas/Missouri BNDD Change of Address Case Log Photograph For Identity Compliance Training/Exams (HIPAA,Privileges) DEA application fee is $390. The certificate must reflect where your prescribe or administer drugs. If you practice at academic institution, this fee may be waived. If you practice at more than one state, separate DEAs are required. If you have more than one office In the same state, if you only administer and/or dispense at the principal office and only write prescriptions at the other office, only the principal office needs to be registered. BNDD � State of Missouri and other require separate state Narcotics and Dangerous Drugs certificate. Cost is $90. For each office in Missouri that you are required to have a DEA, you are also required to have a BNDD with the same address if you handle narcotics or dangerous drugs at that location. If you have more than one office, but only prescribe, BNDD would not be required for office your only prescribe. Change of Address � it is your responsibility to notify all agencies.. Case log/Practice Summary Photograph � Identity theft Compliance training HIPAA specific training for each hospital Moderate/Deep Sedation DEA application fee is $390. The certificate must reflect where your prescribe or administer drugs. If you practice at academic institution, this fee may be waived. If you practice at more than one state, separate DEAs are required. If you have more than one office In the same state, if you only administer and/or dispense at the principal office and only write prescriptions at the other office, only the principal office needs to be registered. BNDD � State of Missouri and other require separate state Narcotics and Dangerous Drugs certificate. Cost is $90. For each office in Missouri that you are required to have a DEA, you are also required to have a BNDD with the same address if you handle narcotics or dangerous drugs at that location. If you have more than one office, but only prescribe, BNDD would not be required for office your only prescribe. Change of Address � it is your responsibility to notify all agencies.. Case log/Practice Summary Photograph � Identity theft Compliance training HIPAA specific training for each hospital Moderate/Deep Sedation

12. 12 PRIMARY SOURCE VERIFICATION Direct Contact With Sources To Guarantee That Statements Are Legitimate, Unchallenged & Appropriate As defined by JCAHOAs defined by JCAHO

13. 13 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 Application process � some facilities will not start or accept your application if anything is missing. Check with each location. (We want you to give signed application so we can get started.) AMA � AOA/DEA � be sure to keep addresses current. Also � be sure to use the same name on board certifications and sub-certification so that all information is published correctly. ECFMG � Educational Commission for Foreign Medical Graduates. Criminal background check � becoming industry standard for hospitals; not all managed care providers require. Malpractice Claims history � past 5 � 10 years will be checked.Application process � some facilities will not start or accept your application if anything is missing. Check with each location. (We want you to give signed application so we can get started.) AMA � AOA/DEA � be sure to keep addresses current. Also � be sure to use the same name on board certifications and sub-certification so that all information is published correctly. ECFMG � Educational Commission for Foreign Medical Graduates. Criminal background check � becoming industry standard for hospitals; not all managed care providers require. Malpractice Claims history � past 5 � 10 years will be checked.

14. 14 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! Group Practice Affiliations � Need to identify senior member/partner who can address questions on quality. National Practitioner Data Bank �(Page 61-63) originated from the Healthcare Quality Improvement Act of 1986. Repository of all disciplinary actions and malpractice claims since 1991. Once malpractice claims are settled/paid, or disciplinary action is taken that is greater than 30 day period, this is reported and will follow throughout your career. Peer References � conscientious, who will respond promptly. If you are aware that someone is out of town, choose someone else. Once you give a name, we are required to obtain a reference from that person. Timeframe � JCAHO requires processed in a timely manner. Once process is completed, you will receive a letter from the Hospital Board advise of approval of application. Group Practice Affiliations � Need to identify senior member/partner who can address questions on quality. National Practitioner Data Bank �(Page 61-63) originated from the Healthcare Quality Improvement Act of 1986. Repository of all disciplinary actions and malpractice claims since 1991. Once malpractice claims are settled/paid, or disciplinary action is taken that is greater than 30 day period, this is reported and will follow throughout your career. Peer References � conscientious, who will respond promptly. If you are aware that someone is out of town, choose someone else. Once you give a name, we are required to obtain a reference from that person. Timeframe � JCAHO requires processed in a timely manner. Once process is completed, you will receive a letter from the Hospital Board advise of approval of application.

15. 15 REAPPOINTMENT Provisional / Probationary (H) Joint Commission � Every Two Years (H) NCQA (Managed Care Organizations) � Every Three Years (M) Main emphasis on reappointments is to verify that you are competent to continue to practice as in the past. Physician Profiles are developed by the hospitals that address severity-adjusted data, core measure and comparative data. Each department set targets for acceptable performance by practitioners. It is the obligation of the medical staff and governing body (hospital board) to ensure that the practitioner�s practice reflects current proficiency. JCAHO is looking for peer recommendations that address Medical Knowledge Technical and Clinical Skills Clinical judgment Interpersonal skills Communication skills ProfessionalismMain emphasis on reappointments is to verify that you are competent to continue to practice as in the past. Physician Profiles are developed by the hospitals that address severity-adjusted data, core measure and comparative data. Each department set targets for acceptable performance by practitioners. It is the obligation of the medical staff and governing body (hospital board) to ensure that the practitioner�s practice reflects current proficiency. JCAHO is looking for peer recommendations that address Medical Knowledge Technical and Clinical Skills Clinical judgment Interpersonal skills Communication skills Professionalism

16. 16 MEDICAL STAFF COORDINATOR Your Best Friend or Worst Nightmare � Your Choice! You will work throughout your career with Medical Staff Coordinators � and if you are conscientious and complete paperwork required for the credentialing process, the medical staff coordinator will be your best friend � if not, you will feel that we are your worst enemies. We are not � we are patient advocates. Our jobs are to gather all the information through your application and reappointment process to give the Credentials Committee the pertinent details needed to recommend your appointment to the Medical Staff. I can assure you that all medical staff offices, be it in a Hospital Setting or Managed Care setting, want to make this process as smooth and simple as possible � we all have quality patient care as our goal.You will work throughout your career with Medical Staff Coordinators � and if you are conscientious and complete paperwork required for the credentialing process, the medical staff coordinator will be your best friend � if not, you will feel that we are your worst enemies. We are not � we are patient advocates. Our jobs are to gather all the information through your application and reappointment process to give the Credentials Committee the pertinent details needed to recommend your appointment to the Medical Staff. I can assure you that all medical staff offices, be it in a Hospital Setting or Managed Care setting, want to make this process as smooth and simple as possible � we all have quality patient care as our goal.