Debra R. Green, MPA, CPMSM, CPCS
Director, Medical Staff Services and General Pediatric Residency Program
Stanford University Medical Center
•Stanford Hospital & Clinics
•Lucile Packard Children’s Hospital
•
•
•
•
•
•
•
Director of Medical Staff Services and Pediatric Residency
Program for Stanford University Medical Center which includes
Stanford Hospital and Clinics and Lucile Packard Children’s
hospital in Palo Alto, CA.
Oversight of a combined medical staff of approximately 2000
physicians, 300+ Advanced Practice Professionals and 78
General Pediatric Residents.
CPMSM and CPCS in addition to a Masters of Public
Administration(MPA) degree with a concentration in Health Care
Management and Policy
20+ years of healthcare administrative experience; primarily
academic.
Held previous leadership positions in New Jersey and Michigan.
Served as an Expert Witness in negligent credentialing and
privileging legal cases
NAMSS Director at Large on the NAMSS Board for 5 consecutive
years.


Overview of the main regulatory bodies
◦ Who they are?
◦ What they do?
◦ Why they exist?
Overview of Credentialing/Privileging
Standards
◦ Requirements
◦ Compliance

Who are they?

What do they do?

Why do they exist?
◦ Government Organization
◦ Surveyors are typically State DOH employees
◦ Gives deeming authority to TJC, HFAP and DNV
◦ Validate TJC
◦ Can Survey For Cause
◦ To ensure patient care and quality

Who are they?
◦ Private Organization





What do they do?
- Unannounced Surveys
- Tracer Methodology
- Can Survey “For Cause”
Why do they exist?
◦ To ensure patient care and quality
Healthcare
Facilities
Accreditation Program
(HFAP)
◦ Deemed Authority since
1965
◦ Surveyors are
experienced healthcare
professionals
◦ Recognized by Fed Gov,
State DOH, Ins Carriers
and Managed Care
Organizations (MCO)
◦ Surveys are unannounced
Det
Norske Veritas
Healthcare, Inc (DNV)
◦ Deemed status since
9/08
◦ Certifies other companies
in additional to healthcare
◦ Existed since 1864
(began in Norway) in US
since 1898
◦ World wide reputation for
quality and integrity

Who are they?
◦ Private Organization

What do they do?
◦ Accredits: MCO’s, MBHO’s, PPO’s, NHP’s etc.
◦ Certifies: CVO’s

Delegated Credentialing Agreements
◦ Hospital does the work for MCO or Health Plan





Who are they?
◦ Private Organization, non-profit
What do they do?
- Accredit Ambulatory Healthcare
Organizations, Surgery Centers, Community
Health Centers and Medical/Dental Group
Practices
- US Air Force and Coast Guard
Why do they exist?
◦ To promote patient safety, quality and value for
Ambulatory health care

Who are they?
◦ Private Organization, non-profit

What do they do?
- Accredit Health Plans and Preferred
Provider Organizations (PPO)

Why do they exist?

◦ To promote healthcare quality through
accreditation education and measurement
programs
TJC
NCQA
HFAP
(I) Primary
Source verification
from Medical
School
(I) Primary source
verification of
(Highest Level of
Credentials)
(I) Primary Source
Verification of
Medical Education
Must be significant
to support request
for privileges
Alternate sources:
AMA, AOA,
ECFMG
AAPA for PA’s
Alternate sources:
AMA, AOA,
ECFMG (for
foreign grads
after 1986),
state licensing
agency (if the
state performs
PSV)
FCVS for closed
residency
programs
Alternate sources:
AMA, AOA,
ECFMG
(after 1986),
state licensing
agency
URAC/AAAHC
URAC – (I) PSV
required
History of
education and
training
included on
app
Can use the state
lic Board as a
PSV
AAAHC – (I) PSV
required
No alternative
sources noted.
DNV/CMS
DNV (I) Primary
Source Verification
of Medical
Education
Requirements
must be outlined in
Bylaws
CMS – Not
specially addressed
in standards
(doesn’t mean its
not required)
TJC
NCQA
(I) PSV required
from primary
source or
equivalent
source
(I) PSV Highest
level of
credentials (i.e.
board
certification)
Alternate
sources:
AMA, AOA
Alternate
sources:
AMA, AOA,
state licensing
agency,
transcripts
(sealed), FCVS
for closed
programs
URAC/AAAHC
DNV
(I) PSV of
Training
required
URAC – (I) PSV
required only
if not board
certified
Documentation
must support
requested
Privileges
History of
Education
Required on
app
DNV - Bylaws
include criteria
for determining
privileges
including,
specific training
requirements
HFAP
Alternate
Sources:
AMA, AOA,
Can use the state
lic board as a
PSV
AAAHC – (I) PSV
required
No alternative
sources noted.
CMS – Not
specifically
addressed in
standards
(doesn’t mean
its not required)
TJC
(I)
Required
(R) Required if there
is insufficient
practitioner-specific
data available
Peer with knowledge
of applicant
Recommendations
should address
clinical competence
and ability to perform
privileges
6 General
Competencies
NCQA
(I&R) Peer Review
through Credentials
Committee with
representation from
similar types and
degrees of expertise
HFAP
(I) Obtain at least
1 peer with the
same professional
Credential
Assessment of
physical and mental
health in relation to
privileges requested.
(R) Individual letters
not required, can be
obtained through
PR, Cred Com,
Dept Chair or MEC
URAC/AAAHC
URAC – No specific
requirement
AAAHC – (I &R)
Peer recommendation
required
DNV and
CMS
DNV- 2 Peer
recommendations at
(I). Nothing in the
standards assess Peer
References at (R)
CMS – Not specially
addressed
 How
many organizations
perform Work/Affiliation
History Verifications?
TJC
There is no specific
requirement for
verification of
work history. The
standards require,
at the time of
appointment to
membership and
initial granting of
privileges,
verification of
relevant training
or experience must
be obtained from
the primary source
(s) whenever
feasible.
NCQA
(I)
PSV not
required.
A minimum of five
years of relevant
work history must
be obtained
through the
practitioner’s
application or
curriculum vitae.
Gaps exceeding six
months must be
reviewed and
clarified either
verbally or in
writing.
HFAP
(I) PSV Required
Verification of
where the
applicant
previously had
privileges with
confirmation of the
applicant’s
appointment and
privilege history,
and any pending
investigations of
disciplinary
actions, voluntary
resignations, or
relinquishments of
membership/clinic
al privileges
URAC/AAAHC
URAC – Not
addressed in
standards
DNV/CMS
DNV – Not
addressed in
standards.
CMS – Not
addressed in
standards
AAAHC – (I)
Reviewed for
continuity and
relevance.
Document
interruptions
in practice
TJC
Clearly
documented
process for
granting
NCQA
No requirement
for privileges
HFAP
URAC/AAAHC
Must be consistent
with demonstrated
competency
URAC – Privileges
must be
included in
the
application
DNV
Criteria Based
AAAHC –
Criteria based
CMS
All patients must
be under the care
of a practitioner
with privileges
Criteria based
Evidence of
Physical Ability to
perform requested
privileges
Grant or Deny
must be objective
and evidence based
Must be criteria
based
Surgical privileges
must be delineated
based on
individual
competency
Reviewed and
approved by
the governing
body
DNV/CMS
Practice within
scope
Privileges can only
be granted by the
hospitals
governing body
Assess ability to
perform
TJC
Can be granted under
2 conditions:
1. Urgent patient care
need for limited time
(PSV current license,
NPDB and
competency
evaluation req)
2. New apps waiting
for MS review and
after a complete
application and All
verifications are
complete
Note: No challenges to
license, membership
or privileges
NCQA
Process for
“provisional
credentialing” for
first time providers
PVS of license, NPDB,
completed application
with signed
attestation
File must be valid and
verified and approved
by Medical Director
or qualified physician
Must not exceed 60
days
HFAP
URAC/AAAHC
Bylaws provide for
the granting of
temporary privileges:
1. During review
and
consideration of
application.
2. For care of
specific patient
URAC – Organization
can grant
“Provisional”
Participation
status for a
limited time
when justified by
continuity or
quality of care
issues on
approval of
senior clinical
staff person.
3. For locum
tenens.
4. For times of
emergency or
disaster.
PSV of Lic, DEA,
Insurance and 1 Ref
from previous facility
req
AAAHC – Not
specifically
addressed.
DNV/CMS
DNV
Urgent Pt Care
Complete app w/o
negative or adverse
info
Not to exceed 30 days
Verification of Lic,
competence, Ref and
AMA (education),
NPDB and OIG
CMS
Not addressed
TJC
(I)
FPPE –
Focused
evaluation
(i.e.
Proctoring)
(R) OPPE –
Ongoing
Evaluation (i.e.
data assessment
for everyone)
Added in MS
Chapter in
2008
NCQA
HFAP
Not addressed
Not addressed
URAC/AAAHC
URAC
Not addressed
DNV/CMS
DNV
Not addressed
CMS
Not Addressed
AAAHC
Not addressed
TJC
NCQA
HFAP
(I & R) Doctor
must provide
information
regarding
previously
successful or
currently pending
challenges or
relinquishment of
registrations
(I & R) Verify
through copy of
certificates, NTIS,
AMA
(I&R) Application
includes actions
against DEA/CDS
State CDS
certificates must
be verified, where
applicable
URAC/AAAHC
URAC –
(I&R)Evidence of
current DEA/CDS
May collect a copy of
certificate or
certificate #
Must be verified
within 6 months of
review and approval
AAAHC – (I)
evaluated at initial
appmt and monitored
continually
DNV/CMS
DNV
(I &R) Provider
must provide
current DEA #
CMS
Not Addressed
TJC
(I & R) LIPS must
participate in
Continuing
Education
NCQA
Not Addressed
HFAP
May request
evidence of CME
every 2 years
URAC/AAAHC
URAC
Not Addressed
Should be relevant
to clinical
privileges
requested
DNV
Should participate
in CME related to
privileges
CME should be
considered at
reappointment
Documented
Considered in
Privilege process
DNV/CMS
AAAHC
Not Addressed for
Medical Staff
Members
CMS
Not addressed
TJC
Not required
unless outlined in
bylaws
Most hospitals
require it
NCQA
Primary source
verification not
required
(I & R) Attestation
by doctor or copy
of policy showing
dates and amount
of coverage or
Face Sheet from
the carrier
Federal Tort letter
or attestation from
practitioner of Fed
Tort is ok
HFAP
Must have
evidence of PLI
coverage
Must have current
certificates
showing amount
(s) of coverage
URAC/AAAHC
URAC – Proof of PLI
included on
application
A cover sheet or
attestation from ins
company is sufficient
to prove coverage
AAAHC – Req only if
organization requires
it
Review information
related to refused or
cancelled coverage at
(I&R)
DNV/CMS
DNV
Not addressed
CMS
Not addressed
TJC
(I & R) evaluate
evidence of
“unusual
pattern” or
“excessive”
number of
actions
resulting in a
final
judgment.
NCQA
HFAP
(I & R) Attestation by
(I&R) Doctor must
provide
malpractice
history for past
five years.
doctor or copy of
policy showing dates
and amount of
coverage or Face
Sheet
Verify history of
claims that result in a
settlement paid by or
on behalf of the
practitioner
Confirm via NPDB or
carrier last 5 years of
settlements
Organization
verify history that
resulted in
settlements or
judgments paid for
practitioner.
Verified through
carrier or NPDB
URAC/AAAHC
URAC – provider
must include
claims history on
app
AAAHC - provider
must include
claims history on
app and evaluated
DNV/CMS
DNV
(I&R)
organization must
review
involvement in any
action
CMS
Not addressed
TJC
NCQA
Must query at
granting of initial,
renewal and when
a new privilege is
requested.
Query if you can’t
obtained last 5
years of claims
from Insurance
carriers.
Use as alternate
source for
sanctions or
limitations on
licensure
HFAP
Must query at
granting of initial
and renewal
URAC/AAAHC
DNV/CMS
URAC - Not
required, but can
be used to verify
license and
Medicare and
Medicaid sanctions
DNV
(I) required only if
Temporary
Privileges are
requested
CMS
Not addressed
AAAHC - required
at (I & R). PDS is
acceptable.
TJC
Terminology is not
used in Medical
Staff Standards
Required under
HR Hospital
Standards
NCQA
Not specially
addressed
Application must
attest to his/her
history of loss of
license and felony
conviction and
lack of illegal drug
use.
*Attestation
Statement
HFAP
Application must
request
information
regarding any
criminal history.
Investigation must
be conducted
based on
information
provided on the
application.
URAC/AAAHC
DNV/CMS
URAC –Not
specially addressed
DNV
Required only if
State requires it
CMS
Required only if
State requires it
AAAHC - Not
specially addressed
NCQA
HFAP
URAC/AAAHC
Verification not
required unless
bylaws /policy
require board
certification
Not required, but
if practitioner says
they are Board
Certified, it must
be verified
(I) Not required,
but if practitioner
says they are
Board Certified, it
must be verified
Organization
Specific
(R) Required to
determine if still
current
URAC - Not
required but
verify if
practitioner
states they are
board
certified
TJC
Verify through
ABMS, AMA,
AOA or specialty
board
Verify Through
ABMS, AMA,
AOA, state
licensing agency if
confirmed by
licensing board
AAAHC – Verify
on initial
application
and ongoing
basis
DNV/CMS
DNV
Not addressed
CMS
Not addressed
TJC
May not exceed 2
years
NCQA
At least every 36
months
Counts the 36
month cycle to
the month, not
to the day. (i.e
Jan 5, 2007 to
Jan 29, 2010 is
ok)
HFAP
May not exceed 2
years
URAC/AAAHC
URAC - At least
every 36 months
Counts the 36
month cycle to
Month AND day.
(i.e Jan 5, 2007
to Jan 28, 2010
is NOT ok) it
must be Jan 5 to
Jan 5 every 3 yrs
AAAHC – as
defined by state
law, not to exceed
3 years
DNV/CMS
DNV
May not exceed 3
years (defined by
state law)
CMS
Recommends
every 24 months
TJC
NCQA
HFAP
(I & R) Primary
source verification
required at initial
appointment,
reappointment,
revision of
privileges and at
time of expiration
(I & R) Primary
source verification
(I & R) Primary
source verification
required
Current and Valid
Verify through
state licensing
board
Must be current
and valid
In effect at time of
credentialing
decision
Verify through
state license board
URAC/AAAHC
URAC – (I&R)
PSV required
Current and valid
AAAHC – (I&R)
PSV required
DNV/CMS
DNV
(I & R) Primary
source verification
required
CMS
Not specifically
addressed in
standards
TJC
NCQA
HFAP
URAC/AAAHC
(I & R) The doctor
must provide
information
regarding
challenges or
relinquishment of
license
(I & R) Primary
source verification
required
Application must
include current or
pending challenges
Verify through
state licensing
board
(I & R) Must be
reviewed for each
applicant
URAC –
History of
sanctions should
include at least a 5
yr history
*Attestation
question
NPDB/PDS and
FSMB can be used
as PSV
FSMB and FACIS
can be used at PSV
State Licensing
Board
FSMB can used as
PSV
NBDB can be used
AAAHC – review
of sanctions
required at (I&R)
DNV/CMS
DNV
Addressed for TP
only
CMS
Not specifically
addressed
TJC
Not addressed
NCQA
(I&R) Current or
previous sanctions
must be verified
Ongoing
Monitoring
required between
re-credentialing
cycles
Verify through
AMA, NPDB,
OIG, FSMB,
FEHB, State
Medicaid Agency
HFAP
Application must
request
information
regarding
Medicare
Medicaid
Sanctions
URAC/AAAHC
URAC
Must be reported
on application
Can use NPDB as
PSV
AAAHC
Must be disclosed
and reported on
application as well
as evaluated at
(I&R)
DNV/CMS
DNV
(I) Must be
reviewed before
Temporary
Privileges are
granted.
CMS
Not Specifically
addressed
TJC
Disaster privileges may
be granted to volunteer
LIPs when the
Emergency Operations
Plan has been activated
*removed from the MS
Chapter, it now resides
in EM 02.02.13
NCQA
Not specifically
addressed.
HFAP
The hospital has a plan
for dealing with clinical
volunteers during
emergency /disaster.
This plan should
provide for primary
source ID from the
volunteer’s
hospital (A documented
phone call is
acceptable).
The hospital should use
volunteers as
appropriate within the
scope of their
license/certification.
URAC/AAAHC
URAC
Not specifically
addressed.
AAAHC
When hospitalization is
needed due to
emergencies, the
organization may have a
policy for credentialing
and privileging
physicians and dentists
who have admitting
privileges at a nearby
hospital.
DNV/CMS
DNV
Not specifically
addressed.
Identification,
availability and
notification of
personnel that are
needed to implement
and carry out the
hospital’s emergency
plans should be
considered when
developing the
Comprehensive
emergency plans.
CMS
Not specifically
addressed.


Be prepared to implement disaster privileges
in the event of an Emergency ……develop a
process, not just a policy
Tool # 2 – Disaster Credentialing Tool Kit

•
•
•

•
•
•
•
•
•
Includes:
Disaster Credentialing Policy
Employee Roster with Phone #s
Disaster Privileging Tracking Logs
(multiple copies)
Disaster Privilege Forms (multiple
copies)
Excerpt from Bylaws regarding
Disaster Privileges
List of Links for licensure verification
Written process for staff to follow
Name Badges
Markers
Ink Pens
To be completed by Medical staff services
L Name
F Name
SAMPLE
DOCTOR
MD, DO, NP, Specialty
PA, DDS,
DPM, PHD
MD
ID Type Key
A – Govt issued ID – REQUIRED
B – ID from another HC Org
C – License to practice
D – ID from DMAT/MRC/ESARVHP
E – ID from Govt entity granting authority to
provide care
F – Confirmation from another Medical
Staff Member
MED
Lic #
123456
Type ID
Provided
(See Key – A
required)
A, B
Lic
Verified
(Date)
Verified
In 72 hrs
Y/N
MS
Member
Y/N
1/1/09
Y
N
PRIV
FORM
COMP
Y/N
Y
VOLUNTEER LICENSED INDEPENDENT PRACTITIONER
DISASTER PRIVELEGES FORM
I, (print)_______________________________________, certify that I am licensed as a:
Physician
Physician Assistant
Podiatrist
Dentist
Psychologist
Nurse Practitioner
in the State of_______________________, license #______________, and I certify that I have no
restrictions on my licensure to practice.
I also certify that I have the training, knowledge, and experience to practice in the specialty of
____________________________________ with no restrictions on clinical privileges at any hospital.
I hereby volunteer my clinical services to Stanford Hospital and Clinics/Lucile Packard Children’s Hospital
(“Hospitals”) during this emergency/disaster situation and agree to practice as directed and under the
supervision of a current member of the Medical Staff at the Hospitals. I agree to wear my ID badge issued
by the Hospitals at all times when functioning under these temporary disaster privileges to enable staff and
patients to readily identify my status.
I agree to abide by all policies at the Hospitals regarding confidentiality of patient information.
I also acknowledge that my temporary disaster privileges at the Hospitals shall immediately terminate once
the emergency has ended, as notified by the Hospitals, and that these privileges may be terminated at any
time without cause or reason, and without right to a hearing or review.
____________________________________________________________
Signature of provider
____________________________________________________________
Date
The information as provided by the provider has been reviewed and will be verified, as soon as possible, as
outlined in the Policy, by Medical Staff Services. On this basis, this provider is herby granted temporary
disaster privileges to treat patients presenting at the Hospital during this emergency/disaster.
____________________________________________________________
Signature of Chief of Staff (or designee)
____________________________________________________________
Date
TJC
NCQA
Applicant must
submit a statement
that no health
problems exist that
could affect clinical
privileges
Current signed
attestation from the
applicant attesting
there are no health
issues.
Confirmed by PD,
Chief of Service or
COS or at another
hospital at (I) appmt
or a Peer already on
staff.
Medical staff must
evaluate prior to
recommending
privileges.
HFAP
Documentation of
Health Status
included in
Professional
references
Can be a statement
regarding the
applicants physical
or mental health
status related to
privileges
requested.
URAC/AAAHC
DNV/CMS
URAC
Application
must include a
question about
physical
mental or
substance
abuse problems
DNV
AAAHC
Not specifically
addressed
Organization
requires and
reviews issues
regarding
physical,
mental and
chemical
dependency
Not specifically
addressed
CMS
TJC
NCQA
HFAP
TJC does not use the term
“allied health
professionals.” It refers
to LIPs and Non-LIPs.
Non-physician
practitioners who have
an independent
relationship with the
organization and
provide care under the
organization’s medical
benefits must be
credentialed.
All practitioners
providing medical care or
conducting surgical
procedures either directly
or under supervision,
whether employed by the
hospital, a physician, or a
contracted provider must
be credentialed.
PAs and APRNs must be
credentialed, privileged,
and re-privileged through
the medical staff process
or an equivalent process
that has been approved
by the governing body.
Equivalent Defined as:
Evaluate credentials,
Current competence,
Peer recommendations
and input from
committees including
MEC to make a decision
about privileges.
Annual competency/skill
assessment required
URAC/AAAHC
URAC
All practitioners who are
participating providers,
provide covered health
care services to
consumers, and appear in
the organization’s
provider directory are
credentialed.
AAAHC
If allowed by the
organization, the board
must provide a process
for the (I) appointment,
(R) appointment, and
assignment or curtailment
of privileges and practice
for AHPs (based on State
law and evidence of
education, training,
experience and
competence
DNV/CMS
DNV
NPs, PAs, DDS,
PHD’s can be
considered
“medical staff in
accordance with
state law
No mention of
requirement for
credentialing and
privileging.
CMS
MS must be composed of
MD and DO, but in
accordance with state
law, NP, PA CRNA, and
CNM can be appointed to
MS.
Physicians and nonphysicians can be granted
privileges
TJC
There must be a
mechanism to
determine the
applicant is the
individual
identified in the
credentialing
documents by
viewing either a
current picture
hospital ID card or
a valid picture ID
issued by a State or
Federal agency,
such as a driver’s
license or passport.
NCQA
Not specifically
addressed
HFAP
Not specifically
addressed
URAC/AAAHC
URAC
Not
specifically
addressed
AAAHC
Not
specifically
addressed
DNV and
CMS
DNV
Not
specifically
addressed
CMS
Not
specifically
addressed
TJC
Not specifically
addressed
NCQA
HFAP
Statement from
applicant required at (I)
and (R) in order to
inquire about:
Although not
specifically
addressed in the
standards, the Scoring
Procedure for the
standard reflecting the
responsibilities for all
credentialed
practitioners
instructs surveyors to
review a select
sampling of files to
verify practitioners
attest to
these responsibilities at
appointment and
reappointment.
Illegal Drug Use
Inability to perform
Loss of Lic/privileges
Disciplinary Actions
Malpractice Coverage
Felony Convictions
Attest that the
application is correct
and complete
Medicare deemed
Organizations: Must
be signed within 180
days of final approval
365 days for nonMedicare deemed Orgs
URAC/AAAHC
URAC
The application
includes a signed and
dated statement
attesting that the
information submitted
with the application is
complete and accurate
to the practitioner’s
knowledge.
Time limit is 180 days
AAAHC
The application
includes a signed and
dated statement
attesting that the
information submitted
with the application is
complete and correct.
DNV/CMS
DNV
Not specifically
addressed
CMS
Not specifically
addressed
TJC
There must be a
process for evaluation
of the credibility of a
complaint, allegation,
or concern against a
privileged provider.
NCQA
HFAP
URAC/AAAHC
A process to monitor
and investigate member
complaints related to
the quality of all
practitioner office sites
is required
QAPI functions include
monitoring of
complaints.
URAC
Policy must define
parameters or triggers
of potential quality of
care issues that require
further investigation.
Must conduct site
visits for complaints
related to physical
accessibility, physical
appearance and
adequacy of waiting
and examining-room
space based on
thresholds. Implements
appropriate actions and
evaluate the
effectiveness of those
actions at least every
six months, until
deficient offices meet
the thresholds.
AAAHC
Not addressed
DNV/CMS
DNV
The hospital must
develop and implement
a formal grievance
procedure, which
includes a referral
process for quality of
care issues to the
Utilization Review,
Quality Management or
Peer Review functions,
as appropriate.
CMS
The hospital must
establish a process for
prompt resolution of
patient grievances and
must inform each
patient whom to
contact to file a
grievance.
TJC
NCQA
A governance standard
holds the hospital’s
governing body
responsible to comply
with applicable law and
regulation.
The administrative
policies and procedures
indicate that
organizations providing
managed care services
must comply with
applicable Federal,
State, and local laws
and regulations,
including requirements
for licensure. Thus, the
organization’s leaders
are responsible for any
regulations relating to
credentialing.
Leaders are responsible
to be aware of and
comply with local,
State, and Federal
regulations related to
credentialing and
privileging
of practitioners.
HFAP
Standards require
compliance with
applicable law and
regulations.
URAC/AAAHC
DNV/CMS
URAC
DNV
Standards require
compliance with all
applicable Federal,
State and local laws.
Standards require
compliance with all
applicable Federal,
State and local laws.
CMS
AAAHC
Standards require
compliance with all
applicable Federal,
State and local laws.
The governing body
must assure that the
medical staff has
bylaws and that
those bylaws comply
with State and Federal
law and the
requirements of CoPs.
TJC
NCQA
Organizations that
use information from
a CVO should have
confidence in the
completeness,
accuracy, and
timeliness of that
information.
CVOs are allowed to
be used and
credentialing policies
and procedures
include the process
used to delegate
credentialing and recredentialing, what
can be delegated, how
the decision to
delegate is made.
Evaluation of agency
can include; processes
utilized, limitations
of information
available,
identification of
primary source info
versus secondary
source information,
quality control
measure, data
integrity, security and
transmission.
A mutually agreed
upon document
describing each
organizations
responsibilities is
required
HFAP
HFAP refers to a
Professional
Credentialing
Organization
(PCO).
PCO can be used to
perform the PSV, but
the process for
credentialing by the
organization must
reflect the
requirements as
stated in the
standards
URAC/AAAHC
DNV/CMS
URAC
The organization can
delegate credentialing
to a network, group
or clinic organization
with which they
contract.
DNV
Oversight is required
CMS
The organization
must retain the
authority to make
credentialing
determinations and
must conduct an onsite survey every three
years.
Not specifically
addressed.
AAAHC
CVO is allowed
Assessment of CVO’s
quality of work is
required
Not specifically
addressed.
TJC
AMA – MD or PA
Education
ABMS – Board
Certification
ECFMG Foreign
Medical Graduates
NCQA
NCQA does not use the
language “designated
equivalent sources.”
The standards refer
back to the specific
credentialing event to
determine an NCQA
approved source.
HFAP
FSMB – Licensure
actions
AMA – MD or PA
Education
AOA – DO Education
and Board Certification
AOA – DO Education
and Board Certification
ECFMG Foreign
Medical Graduates
FSMB – Licensure
actions
NPDB – paid claims or
privilege
suspension/revocation
NCCPA certification
NPDB – paid claims or
privilege
suspension/revocation
ABMS – Board
Certification
URAC/AAAHC
URAC
AMA – MD or PA
Education
DNV/CMS
DNV
AMA – MD or PA
Education
AOA – DO
Education and
Board
Certification
AOA – DO
Education and
Board
Certification
NPDB – paid claims or
privilege
suspension/revocation
CMS
AAAHC
Refers to “secondary
source” list of 20
http://www.aaahc.org/e
web/dynamicpage.aspx?
site=aaahc_site&webco
de=resource_credential
Not specifically
addressed
TJC
Not specifically
addressed.
NCQA
The application must
include a statement
regarding felony
convictions.
HFAP
The application
requests
information regarding
any criminal history
and a criminal
background
investigation is
conducted based on
information provided in
the application or as
required by Federal and
State regulations.
URAC/AAAHC
DNV/CMS
URAC
DNV
Not specifically
addressed.
Not specifically
Addressed
AAAHC
CMS
The applicant must
provide information
regarding criminal
convictions other than
minor traffic violations.
Not specifically
addressed.
TJC
Not required.
NCQA
The organization
implements
appropriate
interventions by
conducting site
visits of offices
about which it
has received
member
complaints and
those for which
established
thresholds are
exceeded.
HFAP
Not required.
URAC/AAAHC
DNV/CMS
URAC
DNV
Not required.
Not required
AAAHC
CMS
Not required
Not Specifically
addressed


Audit, Audit and More Audits!!!
Tool # 3 – Credentialing Audit Forms
EMPLOYEE #123
Physician Audit Checklist
Provider: _________________________________________
Service(s): _________________________________________
HCC Dates: LPCH = 01/19/12
SHC = 01/23/12
Audited by _____________
180 Days = July 23, 2011 (LPCH) or July 27, 2011 (SHC)
New App: __________
Reapp: __________
Front of File Folder
Board letters
Temporary letters (New Apps only)
<90 days to Board Approval (New Apps
only)
Service Chief Recommendation Form All questions answered
SHC
Faculty: _____
LPCH
ACF: _____
SHC _____
LPCH ____
Community: _____
Privilege Tab
SHC
LPCH
SHC
LPCH
# of cases filled in for Core & Spec privs
(Reapps Only)
Documentation for privileges (X-Ray with
Initials, Sedation, etc...)
Signatures of applicant
email (if forms received electronically)
** Electronic email approval attached?
QM/UM/Legal Tab
** Date Service Chief approved file
Insurance Verification
** Proctors assigned?
Claims History
** Approvals dated prior to HCC Date?
Profiles includes Insurance & Medical
Education (New Apps only)
Profiles includes # of cases done for each
privilege (Reapps only)
Facility:
Insurance - Current
Sanctions & Issues Tab
MSO Checklist included/initialed
SHC NPDB PDS - Date verification printed
(& Initialed)
LPCH NPDB PDS - Date verification printed
(& Initialed)
MSO Checklist complete
OIG - Date Verification printed (& Initialed)
Application Tab
GSA - Date Verification printed (& Initialed)
Photo (New Apps Only)
Provider Verification ID'd (New Apps
Only)
If more than 3 month gap in education or
work history - documentation
Yes answer on attestation form has
documentation
Date application signed by provider
required less than 180 days to HCC
approval
References Tab
CV or Work History Included in month/year
format & Initialed (New Apps only)
CME
OH&S Clearance
HealthSteam confirmed (New Apps Only)
Academic Appt / Fast Fac
Previous Reappointment Application
Evidence Fee collected
email (if forms received electronically)
Reappointment Governing Board date less
than 2 years since last reappointment
Previous Governing Board Letter included
Includes 2 ref for New Appointments
Includes 1 ref for Reapps
Hospital Verifications included
AMA or Edu. Verification (New Apps only)
APP Audit Checklist
2012
Provider ______________________________
Service ________________________
Audit Date SHC 01/23/12 LPCH 2/14/12 Audited by _____________
180 Days = July 27, 2011 (SHC) or August 18, 2011 (LPCH)
New App __________
Reapp _______
Board Letter included
Profile includes Insurance and Medical
Education (for New Apps)
Checklist included/initialed
Checklist complete
Temporary
Less than 90 days to Board approval
Letter from Chief of Staff
Recommendation form
All questions answered
All boxes checked
All signatures present
Date Service Chief approved file
Approval dated HCC or prior
Proctors assigned?
Electronic email approval in file
Application Tab
Yes answer on attestation form has
documentation
Enter Date signed by provider
required <180 days to HCC approval
Provider Verification ID'd (Non Emp only)
Facility
APP-Emp _____
5 Privilege Tab
SHC _____
LPCH ____
APP-Non-Emp _____
Delegation of Svcs Agreement(SHC only)
Cert. of Competence (SHC Reapp only)
Job Description
(SHC only)
Privilege Form (LPCH all; SHC some)
ACLS / PALS (if required)
6 QM/UM/Legal Tab
Insurance Verification
Insurance Current
Claims History
7 Sanctions & Issues Tab
NPDB - SHC - Date Verification Printed
NPDB - LPCH - Date Verification Printed
OIG - Date D Verification Printed
GSA - Date Verification Printed
8 References Tab
New app = 2 peer (1 could be supervising
MD)
Reapp = 1 peer
9 QA folder


Not addressed under:
NCQA
URAC
AAAHC
Very detailed standards for:
TJC
HFAP
CMS
DNV



Prior to Last year, hospitals were required to credential and privilege all
telemedicine providers at the “Distant location”. (Even Tele-radiologists
in Australia).
CMS changed the rule and revised the standard in Last year; published
May 2011

New standard effective July 2011

Hospitals can now rely on the credentialing and privileging of “Distant
Site”

The Joint Commission and HFAP are derived from the CMS

Distant Site: The site where the practitioner providing the
telemedicine services is located.

Originating Site: The location where the patient is being treated.


Here are the options that hospitals and CAHs have under the new rule:
Option 1: Credentialing and Privileging Provided under Contract
A distant-site telemedicine entity, acting as a contractor of services, furnishes its services in a manner
that enables the originating-site hospital to comply with all applicable Medicare conditions of
participation and standards (via contract).
OR
Option 2: Credentialing and Privileging Provided without a Contract
The distant-site hospital providing the telemedicine services is another Medicare-participating
hospital.
AND
The individual distant-site physician or practitioner is privileged at the distant-site hospital providing
telemedicine services, and that this distant-site hospital provides a current list of the physician’s or
practitioner’s privileges.
AND
The individual distant-site physician or practitioner holds a license issued or recognized by the State in
which the hospital whose patients are receiving the telemedicine services is located.
AND
The originating-site hospital has evidence of an internal review of the distant-site physician’s or
practitioner’s performance under these telemedicine privileges and provides the distant-site hospital
this information for use in its periodic appraisal of the individual distant site physician or practitioner.
(Sounds like OPPE to me!!)
OR
Option 3: Originating Site Credentials and Privileges practitioners at the distant site
Organizations can credential telemedicine practitioners the same way that they would credential and
privilege any other practitioner who provides patient care services to patients at the organization
Source: The Searcy Exchange June 2011



If the hospital contracts for telemedicine to be used including the radiology, the
hospital verifies that the radiologist is licensed and/or meets the other applicable
standards that are required by State or local laws in both the state where the practitioner
is located and the state where the patient is located OR is subjected to the credentialing
and privileging process through the medical staff to be approved for providing this
service for the hospital.
Criteria that includes aspects of individual character, competence, training,
experience and judgment is established for the selection of individuals working for the
organization, directly or under contract, and/or appointed through the formal medical
staff appointment process; and, the personnel working in the organization are properly
licensed or otherwise meet all applicable Federal, State and local laws.
The governing body is responsible for services furnished in the hospital whether
or not they are furnished under contract. The organization must evaluate and select
contracted services (including all joint ventures or shared services) (and non-contracted
services) entities/individuals based on their ability to supply products and/or services in
accordance with the organization’s requirements. Criteria for selection, evaluation, and
reevaluation shall be established. The criteria for selection will include the requirement
that the contracted entity or individual to provide the products/services in a safe and
effective manner and comply with all applicable NIAHO standards, and standards
required for all contracted services.

Regulation:
◦ Organized medical staff ; operates under bylaws
that are approved by governing body; responsible
for quality of care.

Compliance:
◦ Bylaws, R&R’s, Cred files, Quality Reports, Meeting
minutes

Regulation:
◦ MS composed of MD’s, DO’s according to state law;
may also include others appointed by Governing
Body.

Compliance:
◦ MS Rosters, Cred Files, Minutes or approved Bylaws
categories.

Regulation:
◦ MS must conduct periodic appraisals

Compliance:
◦ Cred Files, Profiles, Summary Reports of
Credentialing activity, Board minutes documenting
last 2 appraisals

Regulation:
◦ MS must examine credentials of applicants for
membership and make recommendation to Board.

Compliance:
◦ Definition of Creds Review Process in the Bylaws;
MS minutes that document review and
recommendations.

Regulation:
◦ MS must be well organized and accountable to
Governing Body for quality of Medical Care
provided.

Compliance:
◦ MS Org Chart, Bylaws Description, Board Minutes,
definition of MS Composition in Bylaws, Bylaws
approval by Board

Requirement:
◦ MS must adopt & enforce.
◦ Must be approved by Board; include category
descriptions, H&P requirement and criteria for
privileges to be granted; describe MS Organization
and applicant qualifications;

Compliance:
◦ Bylaws, R&R, Minutes, Medical Records (H&Ps),
Quality reports (H&P timelines data)

Requirement:
◦ Secure in all cases of unusual deaths and for
med/legal educational interests.

Compliance:
◦ R&R, Autopsy Policy, QA or PI reports; Medical
Record Review.

As of 2007:
◦ No more than 30 days before or 24 hrs after
admission

Old Requirement:
◦ No more than 7 days before and 48 hrs after



Continuous Readiness:
Increase staff knowledge on policies,
regulations, bylaws, rules and regulations,
privileges
Tool # 1 – Credential Jeopardy Game
100
100
100
100
100
200
200
200
200
200
300
300
300
300
300
400
400
400
400
400
500
500
500
500
500


Contact information:
Email: DeGreen@stanfordmed.org
 Phone: 650-497-8920
Website(s)
Stanford Hospital: http://medicalstaff.stanfordhospital.org/



Lucile Packard Children’s Hospital:
https://intranet.lpch.org/mss/index.html;jsessionid=E579B5885A691DCEF80629F89C3D4E67.Int1