Corporate Compliance

How to audit credentialing and privileging practices

Healthcare Auditing Weekly, November 1, 2005

Last week, we discussed developing a checklist of data that the medical staff's office (MSO) personnel collect and verify when physicians apply for or renew their affiliation with the organization.

This week, we'll continue our discussion of auditing your organization's credentialing and privileging practices by outlining how to choose a sample of credentialing files to review.

First, choose a sample of credentialing files. Choose the number of files to review based on the size of the hospital's medical staff. Many hospitals choose to audit 5% of their files. Pay close attention to common problem areas (e.g., ability to reappoint physicians within JCAHO's required two-year time frame).

Next, review the credentialing files. Look for the following documentation:

  • Licensure-when physicians are licensed in another state, the credentialing office must verify all current licenses and check for sanctions in that state

  • Sanctions-look for a statement from the state licensing board confirming that the physician doesn't have any sanctions

  • Malpractice history-see whether the credentialing office contacted the malpractice insurer to ask about the physician's malpractice history

  • DEA certification-copy of certificates

  • Board certification-verify by contacting the board granting certification

  • Education and training

  • Experience

  • Competency evaluation from peers-the number of peers should be defined in the bylaws or credentialing policies and procedures

      The above tip is an excerpt from the book "Hospital Auditing and Monitoring: Sample Programs for Key Risk Areas." Copyright 2004 by HCPro, Inc. This book is a step-by-step, practical manual that offers sample audit programs for the most troublesome areas that a hospital must audit. The binder and CD-ROM are filled with actual audit programs used by auditors and compliance officers in the field. Click here for more information or to order your copy today.

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