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Credentialing Checklist: What to Check, Double-Check and Triple-Check to Achieve Compliance

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Keeping a well-run credentialing program is a problem for many ambulatory surgery centers. The item is the most-often overlooked on accreditation and reaccreditation surveys for all three major ASC accrediting organizations — the Accreditation Association for Ambulatory Health Care, The Joint Commission and American Association for the Accreditation of Ambulatory Facilities.

Marcy Sasso, CASC director of compliance and operations at Sasso Consulting, says this can be particularly problematic: "In some states, enough non-compliance with credentialing may lead immediate jeopardy and may cause the center to close in order to correct the issues," she says. "Remember, providers want to come to your ASC to perform cases. They are really not aware of all of the regulations and paperwork that the center requires."

Here, Ms. Sasso shares a list of steps ambulatory surgery centers can take to ensure credentialing isn't left out in the cold when it comes to accreditation surveys.

1. Establish a credentialing coordinator. This person should be trained and knowledgeable about the center's credentialing policy and bylaws, as well as state and ASC accrediting protocols for credentialing policy and procedures.

2. Have a system in place to identify credentials about to expire. This can either be an automated computer program or an excel spreadsheet. The credentialing coordinator should send out reminders to the referring physician about renewing credentials in writing at least 30 days before they expire. Consistency is also helpful — arranging reminders so they occur at a similar time each year makes credentialing easier to track.

3. Establish a positive working relationship with referring offices. Referring offices can be busy and may not have strict accreditation guidelines themselves. The coordinator should make them aware their physicians won't be able to bring cases without updated credentials.

4. Have several basic credentialing packets already made up and ready to go. Add specialty privileging forms as necessary. When an initial application is sent, the coordinator should follow up to ensure the applicant understands what is due back, offer a facility tour and discuss preference cards and the facility booking process.

5. Carefully review the completed request for privileges form. What is a staff member asking to perform, and does your ASC allow these cases with or without educational training? Who is reviewing this request for privileges, and will they need special equipment to do so? Be sure any necessary forms or letters are on file.

6. Once approved, be clear on privilege expiration dates.

7. Double-check the required documentation is on file in accordance with center policy, including:

•    National Physician Data Bank or American Medical Association report for credentialing verification
•    Office of the Inspector General report to check for billing fraud.

Remember, physicians may not practice before files are complete. This is considered non-compliance for CMS along with most other accrediting bodies.

8. Update minutes. They must reflect an addition or deletion of a physician, even if an in-active status is temporary. The minutes must also reflect specialty or CPT code addition

9. Perform random file audits. Ideally, this should be done by someone other than the credentialing coordinator.

More Articles on Accreditation:
Refresher Course: How Can My ASC Prevent Sharps Injuries and Stay Compliant?
Credentialing Tip: Assign a Coordinator
5 Key Thoughts for Performance Improvement

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