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Step-by-step credentialing

Credentialing Resource Center Insider, July 12, 2007

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Sally J. Pelletier, CPMSM, CPCS, is a consultant with The Greeley Company, a division of HCPro, Inc., specializing in the areas of credentialing and privileging.

Dear credentialing colleague:

I've been transferring my data to a new laptop over the past couple of weeks and installing all of the related software. When installing software, of course, one needs to carefully follow the directions and complete the steps in the proper order. It wouldn't make sense to jump to step #5 if steps #3 and #4 hadn't been completed. The principles of credentialing are also a step-by-step process, with each step playing a critical role in ensuring a strong credentialing process that is as risk adverse as possible.

Greeley consultant Vicki Searcy, CPMSM, does a great job of explaining the four credentialing steps in Credentialing Audits: Tools for Compliance and Reduced Liability (2006, HCPro, Inc.). She writes:

Establish policies and rules

First, your organization must describe your credentialing process in formal documents, such as the medical staff bylaws, documents that supplement the bylaws, or other credentialing plans. Accreditation standards and regulatory requirements that pertain to a particular type of healthcare organization will specify which documents must include credentialing and privileging process information, as well as what information your organization should include.

In addition, healthcare organizations are required to have privilege forms so they can delineate and grant clinical privileges to practitioners. Privilege forms often include criteria that applicants must meet to qualify for a specific privilege or group of privileges.

The language contained in the bylaws, documents that supplement the bylaws, plans, policies, procedures, and privilege delineation forms establishes the policies and rules related to the credentialing and privileging processes.

Collect and summarize information

The collection and summarization of data involves first obtaining information about a practitioner and then verifying that information with primary sources. You will collect much of the information from application materials that the practitioner submits. This process, performed by the healthcare organization, requires verification of the following factors:

• The practitioner's education
• His or her training
• Any clinical experience he or she has had
• Contact with individuals who can attest to the current clinical competence of the practitioner

Once you have collected and verified the information, hospital management and the medical staff are responsible for summarizing it in a format that is useful to those individuals and groups charged with evaluating it and making a recommendation about whether the practitioner should be given access to patients within the healthcare organization.

Evaluate data and make a recommendation

Those individuals and groups charged with evaluating the applicant's information will specifically address in their recommendation which clinical privileges the organization should grant the practitioner. This involves matching the verified data on the practitioner's current clinical competence to the specific privileges that he or she has requested-the heart and soul of a hospital's credentialing process.

Approve or deny credentials

The hospital's governing board makes the final decision about whether a practitioner will receive credentials and privileges based on the verified information and the recommendations made by designated evaluators. Note that in a health plan or managed care organization, the final decision is usually made by a credentials committee.

Remember, credentialing has no other master than the patient.

That's all for this week.

All the best,

Sally J. Pelletier, CPMSM, CPCS

www.greeley.com/consulting.cfm

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