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318 Cards in this Set
- Front
- Back
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What two accreditors state: a hospital may not rely solely on board certification when considering practitioner for medical staff membership? |
HFAP, CMS |
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According to JC & HFAP name four approved sources PSV for Medical Education |
Medical School, AMA, ECFMG, AOA |
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According to NCQA practitioners must be notified of credentialing decision within how many days? |
60 Days |
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The DHHS mails a copy of the NPDB report to the named provider. If the provider wishes to dispute the reports accuracy, the provider has how many days to do so? |
60 Days |
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According to URAQ, within how many days must the practitioner be notified of credentialing decisions? |
10 Days |
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How many days does a practitioner have to dispute an NPDB report accuracy |
60 Days |
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Which accrediting body requires five year verification of malpractice history |
NCQA |
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What is commonly used source for verifying malpractice history |
NPDB |
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According to the JC a fair hearing and appeals process as described in the medical staff bylaws is available to whom? |
Medical staff members and non-members holding clinical privileges |
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T/F Only the highest of training must be verified according to NCQA |
True |
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According to the Joint Commission a peer recommendation should address what six competencies? |
Medical knowledge Technical & clinical skill clinical judgment interpersonal skills communication skills professionalism |
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Telemedicine - according to JC what two options are available for credentialing a the original site? |
Full credentialing, use of the distant sites credentialing |
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According to JC what is included in the process of planning and implementing privileges? |
Develop & approve procedure list Process the application Evaluate applicant specific information Submit recommendations to governing body for applicant specific delineated privileges Notify the applicant, relevant personnel Monitor the use of privileges |
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Are payments made by a physician in a malpractice claim reportable to the NPDB? |
No |
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Who requires Peer References |
JC, HFAP, AAAHC |
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Who reappoints |
JC, HFAP, NCQA, URAC |
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Who requires an attestation? |
NCQA, URAC, AAAHC |
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Who requires education verification? |
JC, HFAP, URAC, AAAHC |
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Who requires statement regarding felony convictions? |
HFAP, NCQA, AAAHC |
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Attestation must state that the information submitted is complete & correct |
NCQA, AAAHC |
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Attestation must state that the information submitted is complete & accurate |
URAC |
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Attestation must include inquiry regarding illegal drug use? |
NCAQ |
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Attestation must include inquiry regarding inability to perform essential functions? |
NCQA |
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Attestation must include inquiry regarding history or loss or limitations of licensure or privileges or disciplinary actions? |
NCQA |
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Attestation must include inquiry regarding current malpractice coverage? |
NCQA |
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Attestation must include inquiry regarding felony convictions? |
NCQA |
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Applicant must attest to limitations on ability to perform functions of the position with or without accomodation, if any |
NCQA |
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Applicant must attest to lack of present illegal drug use |
AAAHC |
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Applicant must attest to history or loss of license and felony convictions, if any |
AAAHC |
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Applicant must attest to history of loss or limitations of privileges or disciplinary actions, if any |
AAAHC |
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Applicant must attest to current malpractice insurance coverage? |
AAAHC |
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Who requires a malpractice history for applicants? |
JC, HFAP, NCQA, URAC, AAAHC |
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Who must have a process in place to address complaints? |
JC, HFAP, NCQA, URAC |
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Who requires Board Certification? |
None |
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Who requires criminal background checks? |
HFAP |
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Who requires applicant ID |
JC |
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Who requires an NPDB |
JC, HFAP, NCQA, AAAHC |
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Who requires current competence? |
JC, HFAP, CMS |
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How often does the OIG report to the NPDB? |
Monthly |
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Are limitations of the clinical privileges of a psychiatrist for more than 30 days reportable to the NPDB? |
Yes |
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According to the JC, who may amend the medical staff bylaws? |
Governing Body |
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Failure to meet the established qualifications and criteria for appointment should be reported to whom? |
The applicant |
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NCQA requires the MCO to obtain a minimum of ???? years of work history? |
Five Years |
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According to NCQA what policy must an organization have in place to obtain approval to enter into a delegated agreement? |
Credentialing policies |
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Hospitals must query the NPDB when: |
Initial appointment granting of priveleges every two years |
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NCQA requires verifications must be less than how many days old? |
180 |
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What is the verification time limit on malpractice history according to the NCQA? |
180 days |
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Time limited credential must be verified by the CVO within how many days prior to submission to the client? |
120 days |
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According to AAAHC, for initial appointments, in addition to licensure and education, what verification is required? |
Experience and hospital affiliation |
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What accreditation body states "the NPDB is an acceptable source for sanctions or limitations on licensure, Medicaid/Medicare sanctions and malpractice history? |
NCQA |
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Who is required to query the NPDB |
Hospitals |
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Is disciplinary action taken against the license of a dentist reportable to the NPDB? |
Yes |
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Under HCQIA, a hospital failure to report an adverse privilege action lasting longer than 30 days may cause the organization to lose HCQIA immunity for how many years? |
3 years |
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According to NCQA verification of Medicare/Medicaid sanctions can be queried by any of what sources? |
AMA, FSMB, HIPDB, OIG, Sanctions Report, NPDB, State Agency |
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According to NCQA, how often must an organization conduct an audit of the credentialing process delegated to another organization? |
Annually |
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How far back does the Joint Commission require evaluation of malpractice history? |
Back to Medical School |
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According to JC, what source may be used to verify malpractice history? |
NPDB |
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Is an internet verification from a website not contracted by the primary source that attest to the accuracy and timeliness of the information considered a complete verification by NCQA? |
No |
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What accreditation bodies require privileges to be distributed to essential department personnnel? |
Joint Commission - CMS |
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Who requires background checks? |
HFAP (the only organization that requires) |
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Is a payment made by an insurance company reportable to the NPDB? |
Yes |
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According to NCQA what providers are NOT required to be credentialed when working in an independent relationship? |
Locum Tenens Hospital based practitioners (i.e., anesthesia, pathology, radiology, etc.) |
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Is denial of a medical license application by a state medical board reportable to the NPDB |
Yes |
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Telemedicine - according to JC what two options are available for credentialing at the originating site? |
Full credentialing Use of the distant sites credentialing |
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What two accreditors state: a hospital may not rely solely on board certification when considering practitioner for medical staff membership |
HFAP, CMS |
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According to who? Medical School, AMA, ECFMG, AOA are approves sources of medical education? |
JC, HFAP |
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According to NCQA practitioners must be notified of credentialing decision within how many days? |
60 Days |
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How long does a named provider have to dispute the accuracy of an NPDB report? |
60 Days |
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According to URAC, within how many days must the practitioner be notified of credentialing decisions? |
10 Days |
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How many days does a practitioner have to dispute an NPDB report accuracy? |
60 Days |
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Which accrediting body requires five year verification of malpractice history? |
NCQA |
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What is the commonly used source for verifying malpractice history? |
NPDB |
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According to the JC, a fair hearing and appeals process as described in the medical staff bylaws is available to whom? |
Medical staff members and non-members holding clinical privileges |
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Who requires only the highest level of training be verified? |
NCQA |
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According to the Joint Commission a peer recommendation should address what 6 competencies? |
Medical knowledge Technical skills Clinical judgment interpersonal skills communication skills professionalism |
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A hospital that does not query the databank as required by HCQIA is |
Legally liable for knowledge of any information reported |
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According to NCQA any gap in personal history greater than ????? must be clarified in writing |
One year |
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According to JC what two verifications must be performed before granting of privileges to satisfy an urgent patient care need? |
Current Licensure Current Competence |
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Name an essential source when developing a peer review policy |
HCQIA |
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According to NCQA what requires ongoing monitoring between credentialing cycles? |
License sanctions |
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The HCQIA was passed into law in what year |
1986 |
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HCQIA peer review protections apply to peer review of: |
Physicians, Dentists |
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According to URAC the credentialing application must include what? |
Release of information |
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What is the NCQA's requirement for history of felonies on applications and reappointment? |
The application requires a statement from the applicant |
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According to NCQA standards, if deficiences are noted during a site visit an action plan must be developed. The office site must implement the plan within ?????? of the initial visit? |
6 Months |
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If the physician is notified of an adverse recommendation and requests a hearing what is required in the notice? |
1. Place, time and date 2. Hearing date within 30 days from date of notice 3. List of witnesses |
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What is the time limit on PSV of current licensure according to NCQA |
180 Days |
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When an applicant for membership or privileges with a clean application is awaiting approval of MEC and the governing body, temporary privileges may be granted for a limited time not to exceed? |
120 Days |
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What is the NCQA timeframe for appointment? |
every 36 months to the month |
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What is the HFAP appointment timeframe? |
not to exceed 2 years |
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What is JC appointment timeframe? |
not to exceed 2 years |
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What is the URAC appointment timeframe? |
every 3 years to the month & day |
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As defined by state law who had the appointment timeframe not to exceed 3 years? |
URAC |
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Who recommends appraisal at least every 24 months if state law does not establsh? |
CMS |
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Who requires an attestation statement? |
URAC, HFAP, NCQA |
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Who must conduct site visits for complaints & evaluate every 6 months? |
NCQA |
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Who requires CME? |
JC |
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Who requires current competence? |
TJC, HFAP, AAAHC |
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Who says the Governing Board must ensure competence? |
JC |
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Who says if state law requires background checks then they are required? |
CMS |
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Who allows state licensing board to verify education if the state board verifies the credentials? |
URAC |
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Who request felony convictions? |
NCQA, HFAP, AAAHC |
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Professional reference must include health status? |
HFAP |
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Does CMS address sanctions? |
No |
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Who allows FSMB to verify license sanctions? |
JC, NCQA, HFAP |
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Malpractice coverage is necessary for what accreditation systems? |
NCQA, HFAP, URAC |
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Who uses five year history for evaluation of malpractice? |
NCQA, HFAP |
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What is the accepted time limit of malpractice history for URAC? |
6 Months |
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What is the verification time limit for medicare sanctions for NCQA? |
180 days |
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Who has provisional credentialing? |
NCQA, URAC |
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Who has temporary privileges? |
JC, HFAP |
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Who requires peer recommendations? |
JC, HFAP, AAAHC |
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Does NCQA use credentialing committee to make recommendations? |
Yes |
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Can HFAP use credentialing committee to make recommendations? |
Yes |
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Does JC require work history verification? |
No |
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Who on initial appointment review work history for continuity and relevance? |
AAAHC |
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Who requires that all licensed independent practitoners must be credentialed and privileged through the organized Medical Staff structure? |
JC |
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NCQA current licensure verification time limit of CVO? |
120 days |
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NCQA malpractice verification time limits for CVO? |
120 days |
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NCQA time limits on professional liability / malpractice for CVO? |
Must be current, valid and verified within 305 calendar days prior to submission to each client |
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What is the main reason for periodically assessing appropriateness of clinical privileges for each specialty? |
To protect patient safety by ensuring current competency, revelance to the facility and accepted standards of trade. |
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Telemedicine originating site is? |
Site where the patient is receiving care is located |
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This legislation prohibits a physician with a financial arrangement with an entity from referring Medicare or Medicaid patients to that entity. |
Stark Law |
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Verification time limit for licensure per NCQA CVO standards? |
120 days |
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Per NCQA standards on initial applications, review of information on sanctions, restrictions, on licensure and limitations on scope of practice must cover what period of time? |
The most recent 5-years |
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In the MCO, a review board or Governing Body may review a credentialing decision after the Credentialing Committee approval. What date does the NCQA use when assessing performance against timeliness requirements for PSV? |
Decision date of the Credentials Committee |
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JC approved designated sources for verification against a physician's medical license? |
FSMB, State Medical Boards |
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This federal law was enacted for the purpose of encouraging good faith professional review activities: |
Health Care Quality Improvement Act of 1986 (HCQIA) |
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At reappointment NCQA requires 4 factors within prescribed time limits: |
1. DEA or CVS 2. Board Certification 3. Liability Claims, settled or judgments 4. Licensure |
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What are the CMS criteria for selection to the medical staff? |
Competency
Character Judgment Experience Training
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NCQA requires these factors prior to provisional credentialing? |
Current license Past 5 years of claims, settlements or NPDB report Application with signed attestation |
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AAAHC requires recredentialing every 3 years except for: |
When state regulations require less time |
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AAAHC requires PSV of the following elements upon initial application: |
Experience reviewed including gaps Peer evaluation Liability insurance NPDB education, training experience current state license DEA |
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What is the verification time limit for licensure per NCQA CVO Standards? |
120 Days |
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Who requires participation in CME be considered in decisiions about reappointment to membership on the medical staff or renewal or revision of individual clinical privileges? |
JC |
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Does JC consider CME in decision making at initial appointment? |
No |
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According to NCQA standards, on initial application, review of information on sanctions, restrictions on licensure and limitations on scope of practice must cover what period of time? |
Most recent five year period |
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CCJET |
Competence Character Judgment Experience Training |
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URAC standards require PSV of what two elements when it initially credentialing a provider. |
State License Highest level of education |
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URAC Standards require The organization to provide written notification to providers within how many calendar days of the credentialing determination? |
10 Days |
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In regards to the credentialing process, NCQA standards require the organization to have written policies and procedures to delineate a practitioners rights. These include: |
1. The right to review information submitted to support the credentialing application. 2. Right to correct erroneous information 3. Right to receive notification of these rights 4. Right to receive status application upon request |
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When credentialing, NCQA requires the organization to verify four factors that can prescribe time limits. What are they? |
1. DEA 2. Board certification 3. History of professional liabilities resulting in settlement 4. Licensure |
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CMS conditions of participation for hospitals require that criteria for selection to the medical staff include evaluation of five areas: |
1. Character 2. Competence 3. Training 4. Experience 5. Judgment |
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NCQA requires verification of which three factors prior to provisionally credentialing a provider? |
PSV current license Past five years malpractice or NPDB Current signed application with attestation |
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AAAHC standards require PSV of a number of elements on initial application. Name them: |
1. Education 2. Training 3. Experience 4. Current state License 5. DEA 6. NPDB 7. Peer references 8. Experienced review 9. current malpractice insurance |
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What is EMTALA |
Emergency transfer and active labor act or Federal antidumping law. |
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What is the purpose of EMTALA |
To prevent hospitals transferring, discharging, or refusing to treat indigent patients coming to the emergency department because of cost factors. |
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Are medical malpractice payors required to query the NPDB? |
No |
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Name two sources of verification of education of a chiropractor according to NCQA? |
1. Chiropractice college 2. State Licensing Agency |
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According to URAC what must be verified using PS? |
State Licensure highest level of education |
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According to NCQA what verificatin is required before provisional credentialing is permitted? |
1. Current licensure 2. 5 year malpractice history |
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NCQA requires applicants to confirm good health & competence to perform essential functions. How is this achieved? |
Signed attestation |
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Within how many days must a medical malpractice payor report payment resulting from written claim or judgment to the NPDB & state licensing board? |
30 days |
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What is the verification time limit for verification of Medicare/Medicaid sanctions according to NCQA? |
180 days |
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What came first, NPDB or HIPDB? |
NPDB |
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According to NCQA, how long is the signature on the attestion good for? |
365 days |
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According to NCQA how long is the signature on the attestation good for, for the CVO's? |
305 days |
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According to URAC who should oversee the clinical aspects of the credentialing program within the organization? |
The Senior clinical staff person |
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Name 3 sources of verification of education of a dentist according to NCQA? |
1. Dental School 2. Specialty Board 3. State Licensing Board |
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NCQA requires MCO's to recredential practitioners every: |
3 years |
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What six criteria are observed in an initial site visit by NCQA? |
1. Physical accessibility 2. Physical apperance 3. Adequacy of waiting and exam rooms 4. Appointment availability 5. Adequacy of treatment 6. Record keeping processes |
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According to JC what should be used to verify current competence? |
Hospital verification |
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According to NCQA who has ultimate authority in credentialing decisions? |
Credentials committee or medical director if it is clean file |
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Name the six general competencies according to the ACGME & ABMS |
1. Patient care 2. Medical/Clinical knowledge 3. Practice based learning and improvement 4. Interpersonal & communication skills 5. Professionalism 6. System based practice |
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According to NCQA application, PSV must be dated within ????? days of the credentialing decisions? |
180 days |
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According to NCQA what credential must be verified at the time of recredentialing? |
Current malpractice State Licensure |
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According to NCQA, how long is the board certification good for? |
180 days |
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Professional societies must report adverse actions or payouts within how many days to the NPDB? |
15 days |
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Hospitals and healthcare entities must report adverse actions within how many days to the NPDB? |
15 days |
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State Licensing board must report adverse actions within how many days to the NPDB? |
30 days |
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Malpractice payors must report adverse actions or payouts within how many days to the NPDB? |
30 days |
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Name 3 sources of verification of education of a podiatrist according to NCQA? |
1. School 2. Specialty board 3. State Licensing agency |
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DEA Registration: High abuse Potential - No medical Use |
I |
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Which JC terminology references the new and revised elements of the accreditation and survey process? |
New pathways |
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According to NCQA a set of standardized measures used to compare health plans is??? |
HEDIS |
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NCQA grants a CVO certification of a period of? |
2 years |
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The medical staff is actively involved in measuring, assessing, and improving what? |
Patient safety data |
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DEA: High abuse potential with dependence liability |
II |
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Who/what is the highest level of authority for URAC? |
The Credentials Committee - May delegate "clean" applications to Senior clinical staff person" |
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DEA: Less abuse potential, moderate dependence? |
III |
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What is a committee of the whole? |
The medical staff as a whole carries out the governance functions. |
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When did the organized medical staff get it's start? |
1917 |
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Who published the "Hospital Standards"? |
American College of Surgeons |
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Per NCQA Standards what is the time limit for provisional credentialing? |
60 days |
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According to HFAP standards temporary privileges may be granted in what cases? |
1. For time of emergency or disaster 2. Locum tenens 3. During review and consideration of application 4. For care of specific patients |
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Per URAC Standards, who has final authority to approve/disapprove applications? |
Credentials Committee |
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EMTALA |
Emergency Treatment and Active Labor Act |
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According to URAC how is the recredentialing cycle calculated? |
MM/YY to MM/YY |
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According to URAC, who should oversee the clinical aspects of the credentialing program within the organization? |
Senior Clinical Staff person |
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What federal system is a list of individuals and firms excluded by Federal government agencies from receiving federal contracts or federally approved subcontracts and from certain types of federal financial and nonfinancial assistance and benefits? |
EPLS |
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What is Statuary Law? |
Legislation passed by democratically elected state legislatures and federal congress |
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DEA: Less abuse potential, limited dependence |
IV |
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In what circumstances does JC permit the granting of temporary privileges? |
1. To fulfill an important patient care need 2. When a new applicant with a complete, "clean" application that raises no concerns is awaiting review and approval of the medical executive committee & board |
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Privileged motions include: |
1. Adjourn 2. Recess 3. Question of privilege |
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According to NCQA Standards, a copy is acceptable certification of the document: |
Medical School Diploma |
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Which accreditation bodies have standards for medical record documentation and confidentiality? |
JC, NCQA |
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Subsidiary motions include: |
1. Lay on the table 2. Previous question (end debate) 3. Commit or refer (committee) |
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According to NCQA, the timeframe within which the DEA verification is permitted is: |
No timeframe, must be current at the time of credentials committee review |
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According to URAC, PSV or secondary PSV may not be collected: |
More than 6 months prior to Credentialing Committee |
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Does NCQA require Locum Tenens to be credentialed when working in an independent relationship within the inpatient setting? |
No |
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NCQA requirements for Professional Practice Questions include: |
1. The correctness and completeness of the application 2. Current malpractice coverage 3. Lack of present illegal drug use |
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JC requirements for Professional Practice Questions: |
Voluntary and involuntary limitation, reduction or loss of clinical privileges |
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NCQA requirements for delegated credentialing are permitted under a written delegation document that includes: |
1. Be mutually agreed upon 2. Describe the delegated activities 3. Describe the responsibilities of the organization and the delegated entity |
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According to URAC, no credentialing application may be accepted if it is signed and dated more than: |
180 days prior to Credentialing Committee review |
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Which of the following specifically require an attestation |
1. NCQA 2. URAC 3. AAAHC |
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Who allows credentialing information from another healthcare organization such as a hospital or group practice to be accepted for credentialing? |
AAAHC |
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The Medicare Conditions of participation are contained in what federal regulation? |
Code of Federal Regulations |
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DEA: Limited abuse potential |
V |
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According to NCQA Standards, which credential MUST be obtained at the time of credentialing? |
Current malpractice insurance certificate |
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Which accrediting bodies require a process to address complaints? |
JC NCQA HFAP URAC CMS |
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According to JC what document may be obtained to verify current competence? |
Hospital verification |
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Per JC what must decisions on membership and granting of privileges consider? |
Criteria directly related to the quality of healthcare, treatment ad services |
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Motions are ranked in the following order: |
1. Privileged 2. Subsidiary 3. Main |
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HIPPA regulations are divided into four Standards or Rules: |
1. Security 2. Identifiers 3. Transactions and Code Sets 4. Privacy |
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A main motion: |
Brings an item of business to the body for consideration |
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CMS criteria for selection to the medical staff: |
CCTEJ Character, competence, training, experience, judgment |
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According to NCQA requirements, the verification time limit for work history is |
365 calendar days for Health Plan 305 calendar days for CVO MA deeming surveys 180 calendar days |
|
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Per NCQA the following must be verified at time of recredentialing: |
1 LIcense 2. DEA 3. Board Certification 4. Medicare/Medicaid Sanctions 5. Malpractice claims |
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Who specifically requires peer References? |
1. JC 2. HFAP 3. AAAHC |
|
|
Who requires a statement by the applicant regarding felony convictios? |
1. NCQA 2. HFAP 3. AAAHC |
|
|
What is the purpose of the Stark Law? |
To prohibit a physician who has a financial relationship with an entity from referring Medicare or Medicaid patients to that entity for the provision of a designated health service |
|
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Why was the HIPDB created? |
To combat fraud and abuse in health insurance and healthcare delivery and to promote quality care |
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Joint commission define credentialing as
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The process of obtaining, verifying, and assessing the qualifications of a health care practitioner who seeks to provide patient care in or for a hospital
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NCQA defines credentialing as
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A process by which an organization reviews and evaluates qualifications of licensed independent practitioners to provider services to its members.
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The three main reasons for credentialing are
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1. Patient Safety2. Risk Management concerns3. Required by accrediting and regulatory agencies
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What does CoPs stand for
|
Medicare Conditions of Participation - The CoPs are contained in the code of federal regulations are intended to protect patient health and safety and to ensure quality of care for hospitalized patients
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Why get accredited |
Accreditation assists organizations in monitoring and improving quality of care. It can be used to meet certain Medicare certification requirements, organizations that are accredited are given "deemed status" meaning they meet the Medicare and Medicaid requirements for participation.
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Other reasons to become accredited
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1. may favorably influence liability insurance premiums2. may be required in order to obtain managed care contracts3. Employers and unions may require accreditation for providing health care coverage to employees
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After CMS approves an Accreditor they are given deemed status, name the accreditors that have deemed status
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1. The joint commission TJC2. American Osteopathic Association Health Facilities Accreditation program (AOA-HFAP)3.Det Norske Veritas Healthcare Inc. (DNV)4. National Integrated accreditation for healthcare organizations (NIAHO)5. National committee for quality assurance (NCQA)6. URAC7. Accreditation association for ambulatory health care (AAAHC)
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What is Compliance
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Participate in the development, implementation, an ongoing assessment of bylaws, rules and regulations, policies & procedures to ensure continuous compliance with accreditation regulatory standards.
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What is the MSO
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Medical Staff Organization - although various regulatory agencies & Accreditation bodies require certain organizational components, the formal structure and specific operational mechanisms are at the discretion of the MSO and governing body of the healthcare organization
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What are the functions of the MSO
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Providing patient care, evaluation the quality of patient care, maintenance of the MSO.
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What is the medical staff
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It is a self governing entity which exists as an extension of the healthcare facility
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How is the medical Staff structured
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the organizational structure of the medical staff as delineated in it's bylaws defined the framework within which medical staff appointees act and interact in hospital related activities.
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Bylaws - why are they written
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Bylaws are written to conform to generally accepted guidelines for broad content categories - they ensure compliance with legal requirements and accreditation and regulatory agencies.
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Why review your bylaws
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bylaws are reviewed and appropriate amendments are essential to keep up with changes in accreditation standards and regulatory requirements
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How often should your bylaws be reviewed
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Typically MSO's make provisiton for at least a biennial review of the bylaws.
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Bylaws committee - purpose
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the purpose of the bylaws committee is to review the bylaws and to make recommendations to the medical staff's executive committee (MEC)
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When do bylaw changes go into effect
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bylaw changes are adopted by majority vote of the medical staff. Bylaw changes are not effective until approved by the governing body.
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What should be included in your bylaws
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Bylaws should include all items necessary to provide a basic frame work for the MSO and to fulfill requirements of the law, regulatory agencies, and accreditation bodies. Also some states have specific requirements for elements to be included in bylaws.
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Detail what medical staff appointees may or may not do. such as requirements for specific clinical processes, rules of each clinical department, requirements for ER coverage, guidelines for obtaining consultation, membership dues, provisions for leave of absence, medical records completion, community call coverage requirements, meeting attendance, and other staff responsibilities and prerogatives.
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Rules and Regulations -
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How can changes be made for rules and regulations for individual departments
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the medical staff may delegate the authority for changing the rules and regulations to the MEC.
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describe the course of conduct or action pursued or the management of a matter in certain circumstances. Policies are often used to address internal matters and may be subject to frequent change. The medical Staff may delegate the authority for changing the rules and regs to the MEC.
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Policies and Procedures -
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Why should MSP's be familiar with the regs and accreditation standards that apply to their organization?
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It is a good idea to audit bylaws, rules, regs, and policies to make sure that they comply with state regs and accreditation standards.
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What if you find out you are not compliant with your bylaws?
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You should determine the basis for the bylaw requirement, if it is not required by accreditation standards, state of federal regs, confer with your legal counsel as to whether not to change the bylaws to reflect your current practice.
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Instead of Bylaws what do MCO's use?
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MCO's use policies and procedures to delineate required functions.
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Who gets credentialed
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Hospitals governing body and medical staff define medical staff membership criteria in the bylaws.
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NCQA describes credentialing as-
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The process by which the managed care organization authorizes contracts with or employs clinicians who are licensed to practice independently to provide services to it members.
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Who do the credentialing standards apply to?
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They apply to all licensed practitioners or groups of practitioners who provide care to the organizations members
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What criteria must the bylaws include to meet CoPs requirements
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Your bylaws must describe the qualifications required of a candidate in order for the medical staff to recommend appointment by the governing body.
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Main Motion
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This motion introduces items to membership for consideration and cannot be made when any other motion is on the floor.
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Subsidary Motion
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This motion changes or affects how a main motion is handled. Subsidary motion is voted on before a main motion.
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Call for Order of the Day
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A request to follow the agenda
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Privileged motion
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This motion brings up items that are urgent - unrelated to pending business. Take precedence over all other motions.
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A motion to divide the assemble
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A more exlicit type of vote (show of hands)
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Incidental motions
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Resolve particular questions that arise in connections with the assembly's conduct of business. They take priority over main motions.
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Incidental motions include
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10 things - Objection To Considerations, Point Of Order, Request For Information, Parliamentary Inquiry, Request To Withdraw A Motion, Motion To Determine Manner Of Voting, Request For Division Of A Question, Request For Division Of The Assembly, Appeal Of A Ruling From The Chair, And Motion To Suspend A Rule
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Main Motions
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Bring an item of business to the assembly for consideration.
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Negligent Tort has 4 elements, what are they?
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1. Duty to exercise due care: standard of care, 2. Breach of duty, 3. Injury (no injury - no liability), 4. Proximate Cause: injury must be caused by breach of duty
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Recall motions
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To correct inadvertent errors, reexamine actions on proposals and reverse them. 2 types of motions.
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Secondary Motions
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Facilitate the discussion of main motions and are divided into privileged, subsidiary, incidental, and recall motions.
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Requirements for appointment are called: |
criteria - reflective of education, training current competence, health status, and licensure |
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External Criteria |
Set by forces outside the organization, accrediting & certifying bodies such as JC, NCQA, state and federal regulations such as CMS. |
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Internal Criteria |
Defined by the hospitals medical staff and governing board of the MCO's board |
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Does MCO's utilize Bylaws? |
No, MCO's use polices and procedures to delineate required functions |
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What do Rules and Regulations describe? |
What medical staff appointees may or may not do |
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What do policies and procedures describe? |
The course of conduct or action pursued or the management of a matter in certain circumstances |
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The medical staff may delegate the authority to whom for changing the rules and regulations? |
The MEC |
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Reasons for credentialing |
Patient Safety Risk Management concerns Required by Accrediting and Regulatory Agencies |
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Where are COP's are contained: |
Code of Federal Regulations |
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Who Gets Credentialed? Hospitals Credential: |
All hospital accreditation standards require the medical staff membership criteria be defined in the medical staff bylaws in compliance with state regulations. The hospital may choose to allow both licensed independent practitioners and other non-independent practitioners appointment to the medical staff. |
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Who Does NOT get Credentialed? NCQA |
Those who practice exclusively within the inpatient setting Those who practice exclusively within free-standing facilities Pharmacists working for a pharmacy Locum tenens (unless working for longer than 90 days) Rental network practitioners |
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Who Gets Credentialed? URAC |
The organization verify the professional qualifications of all participating providers as well as facilities that provide covered health care services to consumers. All practitioners listed in the directory must be credentialed. |
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Who Gets Credentialed? Ambulatory Care Facility |
AAAHC requires that the governing body defines criteria for the initial appointment and reappointment of physicians and dentists. They do NOT specify which providers need to be credentialed. |
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Minium criteria for appointment to the medical staff/granting of medical staff privileges include: |
C: Character C: Competence T: Training E: Experience J: Judgment |
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NCQA Attestation addresses the following: |
Reasons for any inability to perform the essential functions of the position, with or without accomodation Lack of present illegal drug use History of loss of license and felony convictions History of loss or limitation of privileges or disciplinary activity Curren malpractice insurance coverage The correctness and completeness of application |
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HFAP application requests information regarding the following: |
Disciplinary actions taken or investigations pending by hospitals or other healthcare facilities, specialty boards, Medicare/Medicaid Actions against DEA Actions listed in the NDB Information regarding criminal history |
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JC evaluates the following information before granting privileges: |
Challenges to any licensure or registration Voluntary & involuntary relinquishment of any license registration Voluntary & involuntary termination of medical staff membership Voluntary & involuntary limitation, reduction, or loss of clinical privileges Any evidence of unusual pattern or an excessive number of professional liability actions resulting in a final judgment against the practitiners |
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URAC applications includes: |
History of sactions loss or limitation of privileges or disciplinary activity Disclosure of any physical mental or substance abuse problems which without reasonable accomodation impede the practitioners ability to provide are according to accepted standards |
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AAAHC organization requires information upon application regarding: |
Information concerning complaints or adverse actions by a professional society, licensure board, licensure disciplinary actions, refusal of professional liability coverage, criminal convictions other than minor traffic violations, Medicare/Medicaid sanctions, current physical/mental health, and chemical dependency problems |
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NCQA Edcation verification time limit: |
None |
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URAC Education verification time limit: |
6 Months |
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URAC verification of Training time limit: |
6 Months |
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Medicare certfiied ASC's |
Who requires the ASC's to have either a written transfer agreement with a hospital or to ensure that all physicians performing surgery in the ASC have admitting privileges at a nerby Hospital? |
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When must ASC's verify admitting privileges |
When they are Medicare Certiied |
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How many member boards and specialties and subspecialties does the ABMS have? |
24 Member Boards 145 Specialties & Supspecialties |
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NCQA Verification time limit for Work History: |
365 Calendar days for Health Plan 305 Calendar Days for CVO 180 Days for Medicare Advantage deeming surveys |
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NCQA Verification time limit for Board Certification: |
180 days 120 days for CVO |
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Does NCQA require verification of Board Certification? |
If the practitioner claims to be board certified, the organization must verify it. |
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Does NCQA require verification of Board Certification at reappointment? |
Yes, if the certification has expired or if additional certification has been added |
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Does URAC require verification of Board Certification? |
Verify Board Certification if this is the highest level of education.
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What is the time limit for verification of Board Certification for URA? |
6 Months |
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When does AAAHC require verification of Board Certification? |
At initial application and ongoing basis. |
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Verification time limit for Licensure according to NCQA |
180 days 120 days for CVO |
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Verification time limit of DEA according to URAC |
6 Months |
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Verification time limit of Malpractice Insurance coverage according to NCQA |
180 Days 120 Days |
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What prohibits unlawful employment discrimination based on race or color, religion, gender and national origin? |
The Civil Rights Act of 1871 |
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Nondiscrimination according to JC |
Consideration of gender, race, creed, or national origin cannot be used in making privileging decisions |
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Nondiscrimination according to HFAP |
Membership critieria cannot include sex, race, creed, national origin, or handicap cannot be impact the applicant's ability to discharge privileges for which were applied |
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Nondiscrimination according to NCQA |
Policies and procedures must explicitly state the steps that the organization takes during the credentialing/recredentialing processes to monitor for and prevent discriminatory practices |
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Nondiscrimination according to URAC |
Credentialing program includes a statement that the organization will not discriminate against providers |
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Nondiscrimination according to AAAHC |
Not addressed |
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Medicare/Medicaid Sanctions/Exclusions: Requirement by JC |
Not addressed |
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Medicare/Medicaid Sanctions/Exclusions: Requirement by HFAP |
Sanctions or disciplinary actions must be reviewed at initial & reappointment. The application requests information regarding disciplinary actions taken or investigations pending by Medicare/Medicaid. |
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Medicare/Medicaid Sanctions/Exclusions: Requirement by NCQA |
Organizations are responsible for ongoing monitoring of Medicare/Medicaid sanctions between recredentialing cycles. |
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NCQA requires a query of Medicare/Medicaid Sanctions by a query from: |
Federal Employees Health Benefits Plan FSMB NPDB/HIPDB List of Excluded individuals and entities (maintained by OIG) Medicare and Medicaid Sanctions and Reinstatement Report State Medicaid agency or Medicare Intermediary |
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Medicare/Medicaid Sanctions Exclusions: Requirement by URAC |
Required to be reported on application |
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Medicare/Medicaid Sanctions Exclusions: Requirement by AAAHC |
Disclosed and evaluated on initial and reapplication |
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What is Current Competence? |
A determination of an individual's capability to perform up to defined expectations |
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Current competence is determined by the JC how? |
Through peer references It is recommended but not required that hospitals base evaluations on the six areas of General Competencies adopted by ACGME and ABMS |
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Current competence is determined by HFAP how? |
Information obtained from residency or facilities where the applicant has been practicing Low volume may require review of procedure logs and competency from other facilities |
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Current competence is determined by NCQA how? |
Not addressed |
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Current competence is determined by URAC how? |
Not addressed |
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Current competence is determined by AAAHC how? |
On initial application. Obtained from peers |
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Attestation time limit for NCQA: |
365 305 For CVO |
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Attestation time limit for NCQA Medicare Advantage Deeming Surveys: |
180 120 for CVO |
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Which accreditation standards address consent and release for credentialing? |
None |
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The release form should permit release of: |
1. Professional evaluations 2. Information from Insurance Carriers 3. Information from hospitals licensure boards, certification boards, insurance plans, etc. |
