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7 Steps to Credentialing Ambulatory Providers

November 2, 2020

Mirror the steps of granting privileges of inpatient care providers to outpatient care providers to assure provider competence, quality care, and organizational compliance.

In this blog, Hugh Greeley offers up steps for credentialing, privileging, and enrollment for outpatient facility providers with the same standards as those used to hire and grant privileges to hospital employees.

With the growing amount of administrative activity of medical staff services teams and human resources professionals, Hugh suggests that much of the screening and credentials verification (licensure, education, training, experience, and other certifications and qualifications) be performed once with the highest quality data and professional verification services to not only reduce the hiring and onboarding activities of the organization but also reduce the duplicative burden on the provider who is applying for privileges and/or employment. Combining the two processes and insisting on quality data and verifications also assures the accuracy and currency of provider credentials.

Once privileges are granted, ongoing monitoring of licensure with real-time reporting closes the loop on patient endangerment and fraud.

The following is contributed by Hugh Greeley, author of Hugh’s Credentialing Digest

The responsibility of a hospital and its medical staff for ongoing monitoring of credentials and performance of physicians providing inpatient care is well understood.

Clearly, the hospital must exercise due diligence prior to granting clinical privileges. This duty is well established in law with legal precedents and the generally-recognized practices followed by most hospitals. Once privileges have been granted, hospitals and medical staffs have further responsibilities involving initial and ongoing supervision.

Ongoing Monitoring and Performance Evaluation

Many refer to these activities as peer review, continuous monitoring, Focused or Ongoing Professional Practice Evaluation (F or OPPE), or perhaps provisional status. Regardless of the term used, the function is similar to make sure that the privileges granted were appropriate and to monitor, on an ongoing basis, the practices of those granted privileges. These functions are analogous to the 90-day performance evaluation for any new employees and to their ongoing supervision.

Many hospitals also recognize that this responsibility applies to those physicians and other independent practitioners who have sought and obtained employment in addition to clinical privileges, and who practice solely in the ambulatory arena.

Reduce Duplication of Efforts with a Single, High-Quality Screening and Credentials Verification Onboarding Process

Due diligence with an initial screening of applicants is necessary for both the employment and privileging processes. (Ideally, the due diligence should be performed once, performed well, and used in both decisions—to hire, and to grant privileges.) In the best of circumstances, there will be no duplication inherent in the processes: there will be one application, one confirmation of necessary qualifications, one criminal background search, one set of references, one of each item needed to confirm both qualification and competence.

The two processes—verifying credentials, managed from the medical staff services department; and onboarding for employment, managed from the human resources department—naturally then diverge, and decisions are made through separate pathways.

A practitioner is employed and often given a job description and granted clinical privileges. He or she then begins to provide care, in this case, solely ambulatory care in an office previously owned by him or her, or in a new office location. Let us remember that we have exactly the same responsibility to initially monitor this new employee (or privileged practitioner) as if he or she were practicing in the hospital. We also have the same responsibility to supervise ongoing practice or conduct OPPE.

The Need for Provider Transparency Doesn’t Stop in the Ambulatory Setting.

Herein lies the so-called rub. The organized medical staff leaders often suggest that they are unable to evaluate work performed in the ambulatory arena. Relevant department chairs deny that they are able to collect data or conduct peer review, as there is no or little hospital volume. This is nonsense. The staff has been evaluating ambulatory work for decades. Most emergency care is ambulatory. Most radiology is as well. A great deal of surgery is now ambulatory (or one day will be especially in light of COVID-19). The lab performs thousands of tests for ambulatory patients. And the list goes on. Providing ambulatory primary care is no different, but we often seem to shy away from this important task.

Guidelines for an Ambulatory Care Provider Compliance Program

Here are a few easy suggestions that may contribute to this effort:

  • Create a department of ambulatory care. (After all, it is likely that more than half the hospital’s revenue is derived from ambulatory work.)
  • Place a good physician leader in charge of it. (Sure, you may have to compensate him or her, but your employed doctors need a manager.)
  • At the medical executive committee (MEC) level, begin to insist upon regular reports about quality and performance. (Yes, the MEC may insist on these reports.)
  • Collect what data and information you have concerning performance. (It is there; we simply must look for it.)
  • Establish forms and systems to display that data and document its evaluation. (This is the easy part; they are remarkably similar to those currently used in the inpatient setting.)
  • Act upon the results.
  • Wait for the next challenge. (It is sure to come.)

License Verification and Ongoing Monitoring of Outpatient Care Providers Reduces Risk to Patients and Demonstrates Best Practice Compliance

Initial medical license verification, plus a national medical license search, shows the status of other medical licenses, if any, that may have been surrendered, suspended, or are in good standing. Managing medical license status is simple with Verisys’ Verified License Search and Status (VLSS) service that monitors licenses and certifications across all U.S. states, territories, and jurisdictions against every taxonomy and specialty licensing board. This service starts with identity verification using scientific algorithms to match records to aliases and other instances where a provider may change his or her name. Notification options include license expiration, required continuing education credits, and adverse findings.

Verisys Corporation automates ongoing monitoring of providers with its proprietary database FACIS® that collects and aggregates data records from 5,000 primary sources and delivers real-time results on provider exclusions, sanctions, debarments, disciplinary actions, and indictments among other critical actionable data insights.

FACIS® has more than 8 million records dating back to 1990 and accumulating to real-time. Having the historical advantage gives a healthcare organization a leg up when it comes to hiring quality providers who are competent and of good character.

For continuous compliance to state and federal regulations as well as those imposed by quality standards organizations such as URAC, NCQA, TJC, DNV, and HFAP, taking extra measures by continually monitoring against primary sources such as the DEA, OFAC, Sex Offender and Abuse Registries, and Social Security Death Master File (SSADMF) secures reimbursement integrity, makes a strong reputational statement, and protects patients from harm and fraud.

Extra measures are turnkey with Verisys’ integrated verification and search results data delivery methodology includes SFTP, API, Verisys Connect®, a self-serve look-up tool, and CheckMedic® a cloud-based integrated provider credentialing platform.

Hugh Greeley Written by Hugh Greeley
Credentialing and Healthcare Industry Expert
HG Healthcare Consultant
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