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Similarities and differences between hospital and managed care credentialing

Credentialing Resource Center Connection, September 23, 2010

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Anne R. Buss, CPMSM, CPCS, is a medical staff consultant based in Fayetteville, AR.

Dear readers,

If you’re a hospital-based MSP and are curious about the verifications your managed care peers perform, or if you’re thinking about making a career change to work in the managed care environment, you may be surprised to learn how similar the two verification processes are.

Below is a list of five ways managed care credentialing is the same as hospital credentialing and five ways it is different.

Alike

• Managed care organizations (MCO) and hospitals use policies and procedures to guide their credentialing processes. 
• Managed care organizations (MCO) and hospitals use similar verification sources, such as the American Medical Association (AMA), American Osteopathic Association (AOA) and Educational Commission for Foreign Medical Graduates (ECFMG®) to verify medical education and residency training.
• Neither require board certification, but if it is required by the entity, it must be verified directly with the specialty board or the AMA master file. 
• Managed care organizations and hospitals verify licensure and sanctions against the license through the state licensing board.
• Managed care organizations and hospitals require and verify professional liability information.

Different

Some of the ways MCOs are different can be linked to their NCQA-accreditation, which differs from Joint Commission accreditation on points such as:

• NCQA requires verification of malpractice claims history for the past five years. The Joint Commission does not have a set number of minimal years that a hospital must verify for malpractice history.
• NCQA doesn’t require that work history be verified, but a practitioner’s statement about work history is required. The Joint Commission doesn’t use the term “work history” but does require hospitals to verify current competency. 
• NCQA doesn’t require verification of a practitioner’s continuing medical education (CME). The Joint Commission requires verification of a practitioner’s CME, including documentation, an attestation, and that the subject matter of the CME be relevant to the clinical privileges requested. 
• NCQA requires a signed attestation statement regarding the correctness and completeness of the application.  The Joint Commission does not use this same terminology but most hospitals include disclosure questions in their applications that cover this.
• NCQA allows MCOs to credential practitioners for up to 36 months while The Joint Commission states that medical staff privileges may not exceed two years or 24 months.

There are some ambulatory systems that are accredited by The Joint Commission and also held to the NCQA standards under MCO contracts.  It really makes life interesting for us credentialing professionals. 

Remember, those who are afraid to ask are afraid to learn.
All the best,

Anne R. Buss, CPMSM, CPCS

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