Everything You Should Know About Privileging

Credentialing process means deciding whether a physician is skillful enough to perform services he wants to perform. This requires a lot of paperwork and can be done differently by different healthcare facilities. Once a physician gets credentials, he can apply for privileges, or the ability to perform specific procedures and treat specific conditions. This is done at each hospital and requires close examination of physician's application.

There are different ways to do the privileging process. The most traditional one is to create a list of all treatments and procedures. Applicants check if the hospital has procedures they wish to do. Then applicants have to prove that they have knowledge and qualifications to perform the desired procedures. Once applicants show that they can perform the procedures, medical staff searches for any subjects to supervision and decides whether to reject the privileges or not. This way of granting privileges allows medical staff to provide recommendations to the board about the applicant. Applicants can request only those privileges they really need and provide documents only for the data that look suspicious to the medical staff.

However, there is one potential problem - sometimes applicants simply forget to mark the procedure. As a result, they're not allowed to perform it. Besides, medical staff is required to check the competency of the physician to perform requested treatments and procedures. And, for example, if the surgeon wants to perform a procedure, he/she will have to check not only surgeon boxes, but OB/GYN and pediatric boxes as well.

Another way is core privileging. In this case, applicants pick one of the predetermined groups of treatments or procedures that are the most common to that specialty. However, medical staff has to include or exclude all procedures in core privilege list.

Whether method you would like to use, applicants have to show their experience, training, education and competence for the privileges they want to get. You should develop a predetermined criteria or standards and then verify applicant's skills against the standards. These criteria should apply to only one procedure or specialty, and not to the whole department. Your standards should be fair, equal for everybody and related to quality health care.

In order to verify education and training you should look at the background of the new recruit. Board certification is also a good criteria, but it should not be the only one in granting privileges.

Current competence can be determined by examining letters of reference which usually include information on the recruit's performance and improvements. Competition may also include examining the number of procedures performed, or patients treated. However, many skills cross over between different procedures, so the number of them may not show real skills of an individual.

After developing new privileging standards, a hospital should send them to a medical executive committee for the approval. The committee will review the standards and make sure they are fair. Then, the final draft is sent to the board. Once they are approved, medical staff has to follow them.

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

Credential Process Made Easy

Credential process has always been an integral part of the process of practicing medicine. For anyone who wants to treat patients, it's essential to have a document that proves they are allowed to do so. Yes, it is as simple as that. Credentialing is something that has been going hand in hand with medicine for many years.

There were times when doctors could simply treat first three patients, get a proper certificate and start practicing. Today, credential process is long and time-consuming and can cause headaches if not managed properly. Whether you're a physician opening a practice or just adding a new doctor to a team, you should start the credential process in advance - sometimes even nine months before you're going to see your first patients. If you're not in the plan, you can't work with patients. If you want to earn money, you have to be credentialed. And to get credentialed without problems, you should continue reading the article.

Get All The Papers Together In Advance
Start organizing everything far in advance. Mobilize your staff as soon as you find out the new physician is coming - or, if you're a solo physician, as soon as you decide where you're going to set up practice. Most of the time, you will need a proof of malpractice insurance and a license before you get all hospital privileges. And you need hospital privileges before you get credentialed by the plans. Note that many hospital committees meet quarterly, so you have to complete all paperwork well ahead of time.

As MD of Bakersfield Orthopedic Medical Group Alfred Coppola states, their manager started managed-care and hospital plans credential process well in advance, so that their new spine surgeon had a full appointment schedule on the same day he started seeing his patients.

Keep Track Of Your Documents
Managed-care plans are well-known for accidentally losing physician documents, applications and other stuff. It is strongly suggested to mail your documents as "return receipt requested". This way, you can at least prove that your application was received. Besides, somebody will have to review your application before sending it. Note that if you leave something blank, you paper can be put to the bottom of the big pile.

If you have some problems, speaking to a manager would be better than speaking to a front-line employee. If you spend some time building relationships with an authority, chances your document will get lost are lessened. It always helps when managers can put your face with your name. If your documents get lost, don't panic - consistent follow-up will help you find them. Call them regularly and ask the same person all the time. They will remember your name and your problem.

Don't think there are unimportant details - submitting incomplete information or leaving blank fields will cause delays as payers don't work on any application until you provide them all information they ask for. Note that a common application misses information in four main areas: malpractice insurance, current work status and work history (don't forget the physician's start date), covering attestations and hospital privileges. Besides, payers always have a deeper look at those who have gaps in service that are longer than a month. Provide all possible explanations in your application, so that nobody will have a reason to require additional details.

Don't be shy and look out for peers. An important part of the credentialing process for any physician is to serve as references for colleagues. If somebody asks you, provide turnaround as quickly as possible to avoid delays. Look out for other physicians and help fellow workers to finish the process.
Check your application multiple times to see if you get all the information right. If you submit everything properly, you will get credentialed within 90 days. And if you make a mistake, you will not be able to work with patients.

Whatever you're going to do, never try to modify any documents - be it letters from committees, letters of reference or any other paper. It can be quite tempting, but don't go for it. Chances that you will be caught are extremely high.

Be aware that the physician credentialing process is always frustrating and lengthy. Keep that in mind and don't act impatient or defensive toward the staff you're going to meet. Wait times often can't be controlled by credentialing staff anyway.

Finally, be thorough with your papers. It requires a lot of time at the beginning, but it will save even more time later.

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

Changes In Physician Credentialing Process

Just recently there have been some interesting changes in legislation concerning health care. New regulations require behavioral health programs to upgrade the standards of credentialing and provide the credentialing process differently.

Before you start worrying how your team is going to handle even more credentialing work, let's have a look at these changes and consider it as an opportunity to improve your administrative process.

How does it change behavioral health programs?
Those health facilities that didn't have licenses must obtain different certificates. Therefore, the following programs now must credential their providers:
• Nonresidential programs, such as day treatment, intensive psychiatric rehabilitation treatment, partial hospitalization, and PROS(personalized recovery oriented services)
• CPEPs (Comprehensive psychiatric emergency programs)
• Hospitals for mentally ill persons
• ACT programs
• Psychiatric inpatient units
• Treatment facilities for youth
• Apartment program

There is also new Medicaid Carve-In that should improve health outcomes, quality of care, and reduce healthcare costs. Medicaid will implement managed-care model instead of fee-for-service model. Within this model, Medicaid will:
• Provide necessary recovery-oriented services
• Ensure individual-centered care management
• Make outcome-based payments
• Provide client choices
• Improve behavioral health services
• Track behavioral health spending

Now, there are Health and Recovery Plans available for people who need significant mental support. To be able to administrate HARPs, a hospital has to increase credentialing requirements and ensure the program has:
• Adequate network
• A process that can handle the new credentialing process
• Experienced staff
• A compliant credentialing process

There is going to be a data management platform that allows hospitals to manage and maintain information about the credentialing process. The main thing you should do to meet the requirements is to constantly update data on the platform. Specifically, answer the following questions to maintain adequacy requirements:
• Is the hospital accessible to the clients?
• Are your providers able to meet the needs of patients?
• Can your patients understand what your providers tell them?

There is a simple solution that helps hospitals meet new credentialing requirements: new software. There are software systems that help handle data collected during credentialing processes. Usually, one system is enough to manage all paperwork. Note that this software can cost quite a lot and may not have a user-friendly interface. However, nowadays almost every person is technologically savvy and can quickly get acquainted with new software. Moreover, modern software is easier to manage and has improved interface.

The credentialing process serves both patients and providers, and physicians have the right to expect recognition of their efforts, so they need to provide relevant information that reflects what they really do in practice. Lots of feedback has been provided concerning unnecessary difficulties during the process, so we can expect further changes that will make everything a lot easier. For now, there are still lots of costly applications and time-consuming processes that physicians have to go through every 2 years.

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

Blind Spots in Physician Credentialing

Every physician knows two questions patients ask - "Have you done this to somebody else?" and "How does the hospital let doctors practice in the facility?" These are understandable and straightforward questions. At the end, we constantly check our all service providers at sites like Angie's Kist or Better Business Bureau. And still, the medical profession and the way its self-policing is shrouded is still a mystery.


One of the main secrets almost all states' health law has is that there is a "corporate practice of medicine" doctrine. It says that hospitals can't employ doctors at all. Confused? It simply means that hospitals can't practice medicine, only doctors can. Never mind that many hospitals advertise they have the best and the most professional doctors in the field. Hospitals can employ administrators, technical personnel and nurses. Doctors, on the contrary, are independent contractors and not hospital employees. That's why when a patient is accidentally injured because of medical errors, the people in the hospital point their fingers at doctors and remind that doctors don't work in hospitals.


But these independent contractor doctors can somehow come to work in hospitals. How? That's the second important secret of the health law - physician credentialing. Credentialing refers to a process that hospitals use to decide whether or not they should let a doctor practice medicine at their facility, including the list of activities that the doctor can perform there. As a simple example, a neurosurgeon may have staff privileges at a certain hospital to perform brain surgery, but not allowed to do other surgeries.


Getting an official permission is a long process, but once a doctor has credentials to work at the hospital, he has to provide the health care that will be reviewed by hospital committees. That is another secret of the law: peer review means a process during which doctor's colleagues discuss and evaluate his performance. It's needed to decide whether the doctor's care is safe. Whether it meets the latest standards of what a professional would do. It sounds quite good and every patient would think this information is useful and comprehensive and would count on it when selecting a doctor. However, health law allows keeping this information confidential and hidden from the public.


As it was stated by the Houston’s Fourteenth Court of Appeals, this confidentiality privilege enjoyed by doctors and hospitals hides all records and proceedings of credentialing documents and keeps them in the complete secrecy. And that is true for many states, which keep confidential all records and proceedings of peer review committee, and communications within the committee are privileged.


Therefore, each time a patient meets a doctor, he has to take a big leap of hope that this particular hospital takes credential process and peer review process seriously. Families and patients can't demand any documentation to review the past outcomes of doctors or whether the doctor had issues with patient safety in the past. In reality, public may find out about incompetent specialists only when numerous unexpected, bad outcomes are publicized through media and lawsuits.


So, when an accident happens, is a hospital responsible for anything at all? Can the hospital be responsible for credentialing a poor specialist, or for letting the incompetent doctor to work and practice medicine at that hospital?


Instead of a negligence standard used in many other cases, when a victim tries to sue a hospital for improper peer review or credentialing of a doctor, health law requires "malice". To put it simply, a patient has to plead and prove that was the hospital, which maliciously allowed that doctor to practice in the facility. And if you think that a reasonable hospital will obviously fire the incompetent doctor, you're wrong.


It's pretty difficult to prove the standard of malice. At the very least, you have to prove that the hospital had a specific intent to cause an injury to the patient. Another option is to prove that it was an omission that involved a certain degree of risk and the hospital was aware of it, but still chose to allow the doctor to practice in the facility with indifference to the safety, welfare and rights of the patient.


So, what can you do to get actual information about your doctor in the secretive environment of health care?


Almost every state has a Medical Board website, which contains profiles of the vast majority of doctors. Besides, when you get to the doctor's office, don't be shy and ask questions.


When you're seeing the doctor, ask him about his medical school, about the residency, whether or not he is board certified and how long he's been practicing in this field.


When a doctor prescribes a drug or procedure, ask about possible side effects, risks and benefits of the treatment, and also ask about any alternative treatments, their risks and benefits. You should also ask about how long a certain treatment has been around, and how long the doctor is practicing it.


Health law has given a one-sided protection to hospitals and doctors when it comes to the decision-making, but nothing prevents you from asking well-informed questions before going forward for a treatment.


Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.