NAMSS education Study Guide for Certified Provider Credentialing Specialist (CPCS)

Introduction to NAMSS and the Credentialing Environment

• What Is NAMSS?:     * The National Association Medical Staff Services (NAMSS) has spent over 40 years enhancing professional development and recognition for medical staff and credentialing services professionals.     * Vision: To advance a healthcare environment that maximizes the patient experience through the delivery of quality services.     * Membership: Includes more than 6,000 professionals from hospitals, medical group practices, managed care organizations (MCOs), and credentialing verification organizations (CVOs).
• Medical Environment Overview:     * Hospital Environment: Influenced by Federal/State laws (HCQIA, Medicare CoPs), accreditation standards (TJC, HFAP, CIHQ, DNV), and ISO 9001 Quality Management Systems.     * Health Plans/Managed Care Organizations (MCOs): Collections of commercial third-party payers and healthcare networks. Influenced by NCQA, URAC, HEDIS, and CAHPS.     * Credential Verification Organizations (CVOs):         * Organization-specific: Handles credentialing for a specific system.         * Independent: For-profit companies contracting with multiple outside organizations.     * Ambulatory Care/Surgical Centers: Influenced by AAAHC, TJC, and CMS regulations.

Credentialing and Privileging Fundamentals

• Definitions:     * The Joint Commission (TJC): Credentialing is the process of obtaining, verifying, and assessing the qualifications of a healthcare practitioner seeking to provide patient care services in or for a hospital.     * NCQA: Credentialing is a process by which an organization reviews and evaluates qualifications of licensed independent practitioners to provide services to its members.
• Reasons for Credentialing:     1. Patient Safety: Ensuring only high-standard practitioners treat patients.     2. Risk Management: Protecting the hospital from liability for substandard clinicians.     3. Requirements: Necessary to meet Medicare Conditions of Participation (CoPs) and accreditation standards.
• Medicare Conditions of Participation (CoPs):     * Contained in the Code of Federal Regulations, intended to protect patient health/safety.     * Requires the governing body to take final action on MS recommendations.     * Requires a separate credentials file for each member/applicant.
• Accreditation and "Deemed Status":     * CMS grants "deemed status" to accreditors whose standards meet or exceed Medicare CoPs.     * Recognized entities include TJC, HFAP, DNV, URAC (for Medicare Advantage), and AAAHC.

Governance: Bylaws, Rules, and Regulations

• Hospitals:     * Bylaws: Framework for medical staff (MS) appointees; must be approved by the governing body. Typically reviewed biennially.     * Rules and Regulations: Detail specific clinical processes (e.g., ER coverage, medical records completion).     * Policies and Procedures: Address internal matters subject to frequent change (e.g., sexual harassment, confidentiality).
• Managed Care Organizations (MCOs):     * Utilize policies and procedures rather than bylaws to delineate functions (e.g., member satisfaction, credentialing).
• Who Gets Credentialed?:     * LIPs (Licensed Independent Practitioners): Individuals permitted by law and the hospital to provide care without supervision.     * NCQA Requirements: Includes all practitioners licensed to practice independently providing care to members under medical benefits (MDs, DOs, chiropractors, podiatrists, nurse practitioners, psychologists, etc.).     * NCQA Exclusions: Practitioners in exclusively inpatient settings (hospitalists) who do not have an independent relationship with the MCO.

Qualifications and Staff Categories

• Core Criteria: Education, training, current competence, health status, and licensure.
• External vs. Internal Criteria:     * External: Set by accreditors (TJC, NCQA) or government (CoPs).     * Internal: Set by the specific facility (e.g., board certification requirements, geographic distance, liability insurance limits).
• Staff Status Categories (General):     * Active Staff: Appointees routinely involved in hospital activities; have voting rights and serve on committees.     * Associate/Provisional Staff: Initial appointment period, often requiring guidance/oversight.     * Courtesy Staff: For providers with primary practice elsewhere; limited admissions.     * Consulting Staff: Do not admit; provide support to attending physicians.     * Honorary/Emeritus Staff: Distinguished retired members; no voting rights.     * Refer and Follow: Allowed to follow patients and review records but cannot perform inpatient services or write orders (except pre-hospitalization admitting orders).
• Specialized Roles:     * House Staff: Interns/Residents. Not usually granted MS privileges unless functioning as LIPs (e.g., moonlighting).     * Hospitalists: Primary focus is general medical care of hospitalized patients.

The Application Process and Review

• Preapplication: Used to screen eligibility before sending a full application.
• Completeness: Applications must be signed, dated, and have no gaps in chronological history.
• Gaps in History: Any unaccounted time (e.g., between medical school and residency) must be explained by the applicant.
• Red Flags:     * Missing dates/gaps.     * Interruption of training.     * Difference between applicant-provided info and PSV.     * Excessive liability history or canceled insurance.     * Ambiguous peer references.
• Case Study: John Anderson King, DO (Christopher Wallace Martin):     * Found liable in 120+ medical malpractice suits.     * Timeline showed erratic residency history (anesthesia, OB/GYN, and Ortho across multiple states) and non-completed programs.
• Application Questions: Must cover felony convictions, hospital suspensions, license restrictions, and DEA/Medicare sanctions.

Allied Health and Advanced Practice Professionals

• AHP/APP Types:     * Dependent: Work only under physician supervision (e.g., dental assistants, scrub techs).     * Independent (LIPs): Licensed to provide care without supervision (e.g., Nurse Practitioners, PAs, Midwives).
• Medicare Requirement §482.12(a)(1): Governing body determines which categories of non-physician practitioners are eligible for MS appointment.
• TJC Approach: Requires any individual providing care without supervision to be credentialed and privileged through the MS process, regardless of MS membership status.

The Approval Process and Authority

• Hierarchy of Approval:     1. Department Chair: Initial review and recommendation.     2. Credentials Committee: Evaluates the file and PSV; makes recommendations.     3. Medical Executive Committee (MEC): Reviews recommendations and forwards to the Board.     4. Governing Body (Board): Ultimate authority and legally responsible for the organization.
• NCQA Credentialing Committee: Must include a diverse range of participating practitioners and documented meeting minutes.
• Expedited (Fast-Track) Appointment:     * TJC allows for clean applications (no issues/limitations).     * Governing body may delegate to a committee of at least two voting members.
• Provisional Credentialing (MCOs):     * NCQA allows a one-time 60-day period for first-time applicants while full process completes.     * Requires PSV of license, 5-year malpractice history, and signed attestation.

Clinical Privileging

• Definition: Authorization of a specific scope/content of patient care services based on credentials and performance.
• Delineation Methods:     * Laundry List: Exhaustive list of specific procedures.     * Category/Levels: Hierarchy based on training levels.     * Core Privileges: Encompasses bundles of treatments/procedures for which the applicant was trained in residency.
• Medicare CoPs for Surgery (§482.51(a)(4)):     * Surgical privileges must be delineated for all practitioners (including PAs, RN First Assistants).     * Roster of privileges must be available in the surgical suite and scheduling locations.
• FPPE (Focused Professional Practice Evaluation):     * TJC requires all new privileges be subject to a period of focused evaluation to document competence.

Temporary and Disaster Privileges

• Temporary Privileges (Hospital):     * Circumstances: Important Patient Care Need (e.g., specialized doctor becomes ill) or Pending Clean Application.     * Limits: TJC allows up to 120 days for new applicants awaiting Board approval.     * Requirements: Query NPDB and verify license/competence before granting.
• Disaster Privileges:     * Activated during an emergency management plan.     * Requires valid government ID and at least one other form of practitioner ID (e.g., hospital ID).     * PSV of license must begin within 72 hours of the practitioner starting work.
• Telemedicine:     * Originating Site: Where the patient is located; retains responsibility for safety.     * Distant Site: Where the practitioner is located.     * Proxy Credentialing: Originating site can rely on the distant site's credentialing if the distant site is Medicare-participating/TJC-accredited.

Approaches to Verification and Sources

• Verification Approaches:     * Internal: Conducted by organization staff.     * Delegated: Contracted to a CVO.
• Types of Sources:     * Primary Source (PSV): Original issuing entity.     * Secondary Source: Recognized when PSV is impossible (e.g., closed hospital).     * Designated Equivalent Source: Agencies/databases identical to the primary source.
• Accreditor Time Limits (NCQA):     * Verification must be dated within 180 days (Health Plan) or 120 days (CVO) of the decision for license/certification.     * Malpractice history: 180 days (Health Plan) or 120 days (CVO).     * Work history query: 365 days.

National Data Banks and Resources

• NPDB (National Practitioner Data Bank):     * Established by HCQIA 1986.     * Collects malpractice payments, licensure actions, and MS privileging actions.     * Continuous Query (CQ): Meets all legal requirements for ongoing monitoring.
• AMA Physician Masterfile: Source for MD demographics, education, training, and specialty board certification (ABMS agent).
• AOA (American Osteopathic Association): Official source for DO training and Osteopathic Continuous Certification (OCC).
• ECFMG (Education Commission for Foreign Medical Graduates): Verifies certification status for international medical graduates (IMGs).
• OIG (Office of Inspector General): List of Excluded Individuals and Entities (LEIE). No payment from Federal programs if service is provided by an excluded party.
• SAM (System for Award Management): Replaced EPLS; identifies debarments/suspensions by Federal agencies.
• FSMB (Federation of State Medical Boards): Physician Data Center (PDC) reports sanctions and education.

Specific Verification Elements

• Education/Training: Highest level must be verified by NCQA. TJC requires PSV of all relevant training.
• Board Certification: ABMS (24 member boards) vs. AOA (16 boards). Grandfathered lifetime certificates exist, but most now require MOC (ABMS) or OCC (AOA).
• Licensure: Must be current and unrestricted. TJC requires PSV at appointment, expiration, and reappointment.
• DEA (Drug Enforcement Administration):     * Checksum calculation: $(1st + 3rd + 5th) + 2 \times (2nd + 4th + 6th) = \text{Sum}$. The last digit of the sum must match the 7th digit of the DEA number.
• Liability History: NCQA requires 5 years of malpractice history PSV.
• Health Status: TJC requires a statement that no health problems exist that affect ability to perform privileges. The ADA prohibits discrimination but hospitals must ensure fitness for duty.
• Peer Recommendations: TJC requires current info on medical knowledge, clinical skills, judgment, interpersonal skills, and professionalism.

Due Process and Appeals

• Substantive Due Process: Adversity must be reasonable, not arbitrary.
• Procedural Due Process: Formal steps for communication and rebuttal.
• Fair Hearing Plan: HFAP requires impartial peers without economic conflict for hearing bodies.
• Managed Care Appeals: NCQA requires a formal process for actions taken for quality reasons.
• Case Law: Webman v. Little Company of Mary Hospital (California, 1995) established that hospitals can deny applications if a practitioner refuses to release records from prior facilities.

Ongoing Monitoring and Recredentialing

• Appraisal Frequency: TJC (not to exceed 3 years); NCQA/URAC (every 3 years to the month); Medicare CoPs (CMS recommends every 24 months).
• OPPE (Ongoing Professional Practice Evaluation):     * Continuous evaluation of practitioner performance (drug use, infections, procedure logs, LOS, satisfaction).
• Expirables Management: Tracking license, DEA, and insurance to ensure no lapses occur between cycles.

Supporting Departmental Operations

• Management Information Systems (MIS): Integrated databases to enhance quality and control costs.
• Data Integrity: Ensuring accuracy/consistency over the life-cycle of data.
• Confidentiality: Credentials files must be secure. HIPAA limits disclosure of patient health info found in peer review documents.
• DRG Validation: Medicare CoPs require a signed "Notice to Physicians" acknowledgment regarding the truthfulness of diagnosis/procedure coding.
• Delegated Credentialing Oversight:     * NCQA requires a pre-delegation audit and annual oversight (5% or 50-file audit).     * Alternative: "8/30 methodology" (if first 8 pass, no further review required).

Medical Staff Meeting Management

• Organization: Most follow Parliamentary Procedure (Robert’s Rules of Order).
• Roles:     * MSP: Coordinator, resource person, facilitator, educator.     * Chair: Calls meeting to order, restates motions, facilitates dialogue.
• Quorum: Minimum number of members needed to transact business (e.g., 20% or 51%).
• Motions Precedence (Highest to Lowest):     1. Adjourn     2. Recess     3. Question of privilege     4. Lay on the table     5. Previous question (close debate)     6. Limit/Extend debate     7. Postpone definitely     8. Refer to committee     9. Amend     10. Postpone indefinitely     11. Main Motion
• Minutes Formatting: Columnar (Item/Discussion/Action/Follow-up) or Narrative.

Study Strategy and Test-Taking Tips

• Success Principles: Manage time, read questions correctly, learn high-level concepts first.
• Multiple-Choice Tips: Cross off wrong answers; look for opposites (one is often correct); go with initial instinct.
• Mnemonics:     * CRAM: Focus on key areas.     * ROY G BIV: Color spectrum as an example.
• Self-Test Highlight Questions:     * Q: Why check exclusions? A: The facility won’t get paid for services by unauthorized providers.     * Q: TJC hospital appointment period? A: Not to exceed three years.     * Q: NCQA clean file final approval? A: Medical Director.     * Q: Robert's Rules usage? A: Used by approximately 80% of organizations.

Exercises and Applications

• Exercise 1 (Bylaws Criteria): Criteria for MS appointment like licensure, education, clinical performance, and cooperativeness must be consistently applied.
• Exercise 3 (Provisional Scenarios):     * Scenario 1 (MCO capacity): Provisional credentialing is appropriate for documented urgent community need (e.g., providers at 6% over capacity).     * Scenario 2 (New Partner): Not appropriate if no urgent current need is established.
• Telemedicine Criteria for Hospitals: Distant-site must provide external review of performance and adverse events back to the originating site for appraisals.
• Minutes Policy: No electronic recording unless authorized by Chairman; erase tapes after official minutes are approved.
• Record Access: Only individuals performing official hospital functions (Medical Staff Officers, Board, Legal Counsel) have full file access. Practitioners have limited access to their own files (application, NPDB queries, proctor reports).