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10 Steps to a Thorough Physician Credentialing Process

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Credentialing physicians for a surgery center is quite an undertaking, considering the amount of information that must be double-checked before a provider is accepted into the facility. Dare Hartsell, RN, MSN, vice president of clinical services for Practice Partners in Healthcare, discusses 10 essential steps to a thorough, effective physician credentialing process.

1. List potential applicants.
Ms. Hartsell recommends surgery centers start the credentialing process by making a list of potential applicants. She says when Practice Partners is developing a facility in a new area, the company starts the credentialing process with the finite group of physicians who will invest in the facility. "That's how we get the short list," she says.

If the center is a multi-specialty facility and the owning entity determines the ASC will have an open staff, the company goes through each specialty and identifies available physicians in the community. A staff member will visit with interested physicians and determine whether the provider would like to apply for credentialing. Ms. Hartsell says Practice Partners does not send out credentialing application packages to physicians before the providers have requested it.

2. Collect up-to-date contact information.
Ms. Hartsell says ASC leaders should make sure the center has an up-to-date database of physician contact information. Some physicians will want to be contacted directly, while others will prefer the ASC go through an office manager or nurse. "Direct contact information is a very simple issue that can cause a lot of difficulties if you don't have it," Ms. Hartsell says. Up-to-date contact information is important because you will need to check in with the physician throughout the process and send multiple forms to his or her office.

3. Provide specific instructions on required information. Make sure physicians and their practice staff have specific instructions on which information is required for credentialing, Ms. Hartsell says. Practice Partners requires a laundry list of information from applying physicians, including information on work history and education, a current CV, board certification and state licensure information, malpractice liability certificate and any controlled substance certificates, among other information. The physician should receive detailed instructions on which information they need to send back to the surgery center and when. Don't leave it up to the practice to determine deadlines and prioritize the importance of the information you need.

Ms. Hartsell says the application should also include a waiver statement that asks the physician to attest to the truth and completeness of the application. Practice Partners then sends a copy of the waiver to the malpractice carrier, any applicable hospitals and peer references.

4. Perform a thorough background check.
The most time-consuming part of the credentialing process is the verification process and background check, Ms. Hartsell says. This process requires a staff member to go through all information provided by the physician and double-check it for accuracy and truthfulness. This might include:

• Verifying training and education through the American Medical Association or the Educational Commission for Foreign Medical Graduates if the applicant was educated outside the United States
• Verifying current medical licensure in the state
• Verifying employment history
• Verifying Medicare sanction information through the OIG sanctions exclusion database
• Querying the National Practitioner Data Bank on closed and settled claims history
• Reviewing any time gaps in education or career (if the applicant has more than a six month period of time when they are not enrolled in a program at a medical teaching institution or employed as a physician, the applicant is asked to provide a detailed explanation on the application)
• Verifying the status of the applicant's privileges at hospitals and other health care facilities as listed on the application

Once the physician's application information has been verified, the surgery center can move on to examining personal references and determining whether the provider is a good fit for the center.

5. Require peer references.
Ms. Hartsell says Practice Partners requires three references from applying physicians. All three references must be physicians of the same specialty who are not related by blood or marriage, and none of the references may be members of the physician's practice. "Many times, with new physicians, those references will be program directors from previous facilities where the physicians completed graduate medicine programs such as residencies and fellowships," she says. "We specify all these requirements on the application."

Ms. Hartsell says the reference requirements at her company are slightly different for allied health professionals than for physicians. "[When] we credential allied health professionals, and certified registered nurse anesthetists, for example, we will allow those references to be anesthesiologists," she says. "It doesn't have to be a CRNA, but a professional who is a licensed anesthesia provider."

6. Weed out poor applications to save money. The credentialing process is time-consuming and expensive for ASCs because centers must dedicate a staff member to comb through applications, prepare letters and other correspondence and continually follow up on the status of any outstanding information. Since each application requires a significant amount of time to verify, Ms. Hartsell recommends "culling the herd" prior to starting background checks. "There is a cost associated with this process, so you don't want your credentialing coordinator to be wasting time on an application that's not going to come to fruition," she says.  

7. Investigate malpractice claims.
While reviewing physician claims history through the National Practitioner Bank and the malpractice carrier, your surgery center may run across information on settlements, closed suits and other malpractice claim information. Ms. Hartsell says the presence of malpractice claims does not necessarily mean the physician should not be credentialed. "It's a red flag, but from our perspective and the way our bylaws are written, a physician can have malpractice claims, closed suits or settlements, and that doesn't mean we won't allow them to have privileges," she says. "It just means we apply additional scrutiny to the application and the physician."

She says the application should include a section for the physician to address malpractice claims and explain, in their own words, the situation. The credentialing coordinator can then compare that information with the physician's claims history to determine whether the information matches. On the other hand, she says a physician who omits information on malpractice claims from his or her application would always raise a red flag.

8. Send applications to the governing body for review.
After the credentialing coordinator has verified the information on the physician's application, the application should go to the ASC's governing body for final review. "This is the time when any red flags and additional information is reviewed and discussed," Ms. Hartsell says. She says a physician who seems like a good match for the ASC — but who has one area of concern for the center on his or her application — might be proctored for the first six months, meaning he or she is overseen by another physician of the same specialty.

9. Verify privileges with local hospitals. When an ASC is developed and equipped, the surgery center leadership determines which specialties the facility will offer and bases the procedure list on procedures approved by Medicare for an ASC. When physicians applies for privileges at a surgery center, they receives a list of approved procedures for their specialty at that specific facility. Physicians can then go through the list and request privileges for the procedures they are qualified for and wish to perform.

If physicians want to perform a procedure outside the standard delineation of privileges for their specialty, they can formally request to perform those privileges if such privileges are on the facility approved procedure list. In that case, the surgery center would ask the physician for documentation that shows he or she has been trained in the specific procedure. For procedures that the ASC already offers, surgery center leadership can contact the physician's affiliated hospitals and request a list of privileges that the physician holds there. This lets the ASC ensure that the physician is trained and experienced in the procedures or she has requested.

10. Use a checklist to track physician progress.
Ms. Hartsell highly recommends that surgery center staff members and credentialing coordinators keep a checklist of the steps for physician credentialing. "Make sure you're checking that checklist on a weekly basis," she says. She says the coordinator should know when each form was sent to the physician's office and when the physician submitted the completed information to the surgery center. The coordinator should also keep track of references that have not responded to the surgery center's request to assure prompt responses.

Learn more about Practice Partners in Healthcare.

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