AUTOMATING THE STAFF ADMINISTRATION, CREDENTIALING AND PRIVILEGING PROCESS

By Bruce W. Johnson, M.S. and Steve Schafer, M.Div.

The Credentialing process traditionally has been used by hospitals to evaluate, verify and approve a physician for the purpose of granting clinical privileges. The privileges are the authorizations granted by the governing body of the healthcare facility to admit, treat and discharge patients based on a practitioner's license, education, training and experience. To facilitate this process a National Practitioners Data Bank (NPDB) was mandated by law in 1986 as part of the Healthcare Quality Improvement Act and started operation in 1990. The Health Resources and Services Administration of the US Department of Health and Human Services manages the data bank. The purpose was to enhance the peer review process in granting and reviewing clinical privileges. Although many outpatient mental health providers do not have the same type of Credentialing process for their clinicians, it is nonetheless their responsibility to their patients to assure that the staff have the necessary credentials to perform the services required. Therefore, many managed care organizations are developing a Credentialing process for Ph.D. and master's level therapists. As with all professions mental health providers are becoming more specialized. Consequently, by definition, certain organizations and individuals will be more effective in the treatment of certain types of patients and illnesses. In order for the triage professional and case manager in a provider network to direct the patient to the appropriate program and therapist, it is helpful to have a staff database that lists the credentials, licenses, education, degrees, experience, areas of specialization and training of the employees as well as the type of patients that they prefer. Additionally, the staff file or "Professional Porfolio" will need to be accessed by a number of different programs when scheduling or billing for services. It should also be available to utilization management and intake staff when authorizing and scheduling services. Since licensing requirements vary by state, it is important that the system have the flexibility to accommodate variations in requirements. Managed care organizations are also referring patients to providers and practitioners on the basis of the efficiency and efficacy of their treatment based on an analysis of previous outcomes and cost. The Joint Commission (JCAHO) has defined Credentialing standards for the provider organizations, while the National Committee on Quality Assurance (NCQA) has standards for managed care organizations and providers. Some of the standards listed by NCQA include: The presence of written policies and procedures for the Credentialing process that include original Credentialing, re-Credentialing, re-certification, and/or re-appointment of any licensed practitioners. The governing body, or group or individual to whom the governing body has formally delegated the Credentialing function, reviews and approves Credentialing policies and procedures. The managed care organization designates a Credentialing committee or other peer review body that makes recommendations regarding Credentialing decisions. The managed care organization identifies those practitioners who fall under its scope of authority and action. The initial Credentialing process is ongoing and up-to-date. At a minimum, the Plan obtains and reviews verification of the following information: The applicant completes an application that includes: A valid license Valid certification Graduation from an approved educational institution, residency and board certification if applicable Demonstrable work experience Professional liability claims history Malpractice insurance if applicable Reasons for any inability to perform essential functions, if any Lack of present drug use History of loss or limitation of privileges or disciplinary actions Attestation to the correctness/completeness of the application Evidence that the managed care organization requests information on the practitioner from recognized monitoring organizations, such as National Practitioner Data Bank, State Board of Medical Examiners, Department of Professional Relations, Licensing Boards, etc. The managed care organization has written policies and procedures for the initial quality assessment of healthcare delivery organizations with which it intends to contract. There is a process of periodic verification of credentials There is evidence that the managed care organization requests information from recognized monitoring organizations. The re-Credentialing, re-certification or performance appraisal process also includes review of data from member complaints, results of quality reviews, utilization management and member satisfaction surveys. The re-Credentialing process includes a site visit to provider's offices The managed care organization has policies and procedures for reducing, suspending or terminating practitioner privileges. If the managed care organization delegates any Credentialing activities to contractors, there is evidence of oversight of the contracted activity. Some specific data elements that a provider organization may want to track on their psychiatrists and other therapists include: Address of clinician Board certification/eligibility DEA number expiration date Clinical privileges assigned Date credentials documented Date admitting privileges granted Date of graduation Date of institution affiliation Date request for application was received Date of teaching engagement Federal tax ID Gender Individual verifying credential documentation Insurance certificate number Malpractice liability insurance limits Monitoring organization confirmation National Practitioner Data Bank (NPDB) Inquiry Results Office phone number Privileges requested Professional liability claims history Professional title Residency/Internship institution Site visit survey results Specialty Teaching appointment institution Sub-specialties (e.g. dual diagnosis, eating disorders, etc.) Organizational Policy and Procedure Orientation Dates UPIN number Application date CDS or DEA certificate Citizenship Credential source documentation Date of birth Date of fellowship Date of graduation from medical school Date of interview(s) Dates of residency Employer ID Fellowship institution Hospital admitting privileges Institution affiliations (multiple) Malpractice liability insurance company Medical school Name of clinician Office address Place of birth Privileges granted Professional references (multiple) Residency program Resume on file (y/n) Social security number State license(s) Termination date for hospital privileges Continuing Education Credits Workshops and Training Work history About The Authors: Bruce Johnson, M.S., is President of Johnson Consulting Services, Inc., an information management consulting firm that specializes in working with healthcare, social service and managed care organizations. He can be reached at (800) 988-0934, www.jcsconsultants.com or by e-mail at jcs@eos.net. Mr. Schafer is a clinical records and operations management consultant. He specializes in working with managed care, behvavioral healthcare and child welfare organizations. He can be reached at (800) 661-2435, www.schaferconsulting.com or by e-mail at steve@schaferconsulting.com.