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318 Cards in this Set

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What two accreditors state: a hospital may not rely solely on board certification when considering practitioner for medical staff membership?

HFAP, CMS

According to JC & HFAP name four approved sources PSV for Medical Education

Medical School, AMA, ECFMG, AOA

According to NCQA practitioners must be notified of credentialing decision within how many days?

60 Days

The DHHS mails a copy of the NPDB report to the named provider. If the provider wishes to dispute the reports accuracy, the provider has how many days to do so?

60 Days

According to URAQ, within how many days must the practitioner be notified of credentialing decisions?

10 Days

How many days does a practitioner have to dispute an NPDB report accuracy

60 Days

Which accrediting body requires five year verification of malpractice history

NCQA

What is commonly used source for verifying malpractice history

NPDB

According to the JC a fair hearing and appeals process as described in the medical staff bylaws is available to whom?

Medical staff members and non-members holding clinical privileges

T/F Only the highest of training must be verified according to NCQA

True

According to the Joint Commission a peer recommendation should address what six competencies?

Medical knowledge


Technical & clinical skill


clinical judgment


interpersonal skills


communication skills


professionalism

Telemedicine - according to JC what two options are available for credentialing a the original site?

Full credentialing, use of the distant sites credentialing

According to JC what is included in the process of planning and implementing privileges?

Develop & approve procedure list


Process the application


Evaluate applicant specific information


Submit recommendations to governing body for applicant specific delineated privileges


Notify the applicant, relevant personnel


Monitor the use of privileges

Are payments made by a physician in a malpractice claim reportable to the NPDB?

No

Who requires Peer References

JC, HFAP, AAAHC

Who reappoints

JC, HFAP, NCQA, URAC

Who requires an attestation?

NCQA, URAC, AAAHC

Who requires education verification?

JC, HFAP, URAC, AAAHC

Who requires statement regarding felony convictions?

HFAP, NCQA, AAAHC

Attestation must state that the information submitted is complete & correct

NCQA, AAAHC

Attestation must state that the information submitted is complete & accurate

URAC

Attestation must include inquiry regarding illegal drug use?

NCAQ

Attestation must include inquiry regarding inability to perform essential functions?

NCQA

Attestation must include inquiry regarding history or loss or limitations of licensure or privileges or disciplinary actions?

NCQA

Attestation must include inquiry regarding current malpractice coverage?

NCQA

Attestation must include inquiry regarding felony convictions?

NCQA

Applicant must attest to limitations on ability to perform functions of the position with or without accomodation, if any

NCQA

Applicant must attest to lack of present illegal drug use

AAAHC

Applicant must attest to history or loss of license and felony convictions, if any

AAAHC

Applicant must attest to history of loss or limitations of privileges or disciplinary actions, if any

AAAHC

Applicant must attest to current malpractice insurance coverage?

AAAHC

Who requires a malpractice history for applicants?

JC, HFAP, NCQA, URAC, AAAHC

Who must have a process in place to address complaints?

JC, HFAP, NCQA, URAC

Who requires Board Certification?

None

Who requires criminal background checks?

HFAP

Who requires applicant ID

JC

Who requires an NPDB

JC, HFAP, NCQA, AAAHC

Who requires current competence?

JC, HFAP, CMS

How often does the OIG report to the NPDB?

Monthly

Are limitations of the clinical privileges of a psychiatrist for more than 30 days reportable to the NPDB?

Yes

According to the JC, who may amend the medical staff bylaws?

Governing Body

Failure to meet the established qualifications and criteria for appointment should be reported to whom?

The applicant

NCQA requires the MCO to obtain a minimum of ???? years of work history?

Five Years

According to NCQA what policy must an organization have in place to obtain approval to enter into a delegated agreement?

Credentialing policies

Hospitals must query the NPDB when:

Initial appointment


granting of priveleges


every two years

NCQA requires verifications must be less than how many days old?

180

What is the verification time limit on malpractice history according to the NCQA?

180 days

Time limited credential must be verified by the CVO within how many days prior to submission to the client?

120 days

According to AAAHC, for initial appointments, in addition to licensure and education, what verification is required?

Experience and hospital affiliation

What accreditation body states "the NPDB is an acceptable source for sanctions or limitations on licensure, Medicaid/Medicare sanctions and malpractice history?

NCQA

Who is required to query the NPDB

Hospitals

Is disciplinary action taken against the license of a dentist reportable to the NPDB?

Yes

Under HCQIA, a hospital failure to report an adverse privilege action lasting longer than 30 days may cause the organization to lose HCQIA immunity for how many years?

3 years

According to NCQA verification of Medicare/Medicaid sanctions can be queried by any of what sources?

AMA, FSMB, HIPDB, OIG, Sanctions Report, NPDB, State Agency

According to NCQA, how often must an organization conduct an audit of the credentialing process delegated to another organization?

Annually

How far back does the Joint Commission require evaluation of malpractice history?

Back to Medical School

According to JC, what source may be used to verify malpractice history?

NPDB

Is an internet verification from a website not contracted by the primary source that attest to the accuracy and timeliness of the information considered a complete verification by NCQA?

No

What accreditation bodies require privileges to be distributed to essential department personnnel?

Joint Commission - CMS

Who requires background checks?

HFAP (the only organization that requires)

Is a payment made by an insurance company reportable to the NPDB?

Yes

According to NCQA what providers are NOT required to be credentialed when working in an independent relationship?

Locum Tenens


Hospital based practitioners (i.e., anesthesia, pathology, radiology, etc.)

Is denial of a medical license application by a state medical board reportable to the NPDB

Yes

Telemedicine - according to JC what two options are available for credentialing at the originating site?

Full credentialing


Use of the distant sites credentialing

What two accreditors state: a hospital may not rely solely on board certification when considering practitioner for medical staff membership

HFAP, CMS

According to who? Medical School, AMA, ECFMG, AOA are approves sources of medical education?

JC, HFAP

According to NCQA practitioners must be notified of credentialing decision within how many days?

60 Days

How long does a named provider have to dispute the accuracy of an NPDB report?

60 Days

According to URAC, within how many days must the practitioner be notified of credentialing decisions?

10 Days

How many days does a practitioner have to dispute an NPDB report accuracy?

60 Days

Which accrediting body requires five year verification of malpractice history?

NCQA

What is the commonly used source for verifying malpractice history?

NPDB

According to the JC, a fair hearing and appeals process as described in the medical staff bylaws is available to whom?

Medical staff members and non-members holding clinical privileges

Who requires only the highest level of training be verified?

NCQA

According to the Joint Commission a peer recommendation should address what 6 competencies?

Medical knowledge


Technical skills


Clinical judgment


interpersonal skills


communication skills


professionalism

A hospital that does not query the databank as required by HCQIA is

Legally liable for knowledge of any information reported

According to NCQA any gap in personal history greater than ????? must be clarified in writing

One year

According to JC what two verifications must be performed before granting of privileges to satisfy an urgent patient care need?

Current Licensure


Current Competence

Name an essential source when developing a peer review policy

HCQIA

According to NCQA what requires ongoing monitoring between credentialing cycles?

License sanctions

The HCQIA was passed into law in what year

1986

HCQIA peer review protections apply to peer review of:

Physicians, Dentists

According to URAC the credentialing application must include what?

Release of information

What is the NCQA's requirement for history of felonies on applications and reappointment?

The application requires a statement from the applicant

According to NCQA standards, if deficiences are noted during a site visit an action plan must be developed. The office site must implement the plan within ?????? of the initial visit?

6 Months

If the physician is notified of an adverse recommendation and requests a hearing what is required in the notice?

1. Place, time and date


2. Hearing date within 30 days from date of notice


3. List of witnesses

What is the time limit on PSV of current licensure according to NCQA

180 Days

When an applicant for membership or privileges with a clean application is awaiting approval of MEC and the governing body, temporary privileges may be granted for a limited time not to exceed?

120 Days

What is the NCQA timeframe for appointment?

every 36 months to the month

What is the HFAP appointment timeframe?

not to exceed 2 years

What is JC appointment timeframe?

not to exceed 2 years

What is the URAC appointment timeframe?

every 3 years to the month & day

As defined by state law who had the appointment timeframe not to exceed 3 years?

URAC

Who recommends appraisal at least every 24 months if state law does not establsh?

CMS

Who requires an attestation statement?

URAC, HFAP, NCQA

Who must conduct site visits for complaints & evaluate every 6 months?

NCQA

Who requires CME?

JC

Who requires current competence?

TJC, HFAP, AAAHC

Who says the Governing Board must ensure competence?

JC

Who says if state law requires background checks then they are required?

CMS

Who allows state licensing board to verify education if the state board verifies the credentials?

URAC

Who request felony convictions?

NCQA, HFAP, AAAHC

Professional reference must include health status?

HFAP

Does CMS address sanctions?

No

Who allows FSMB to verify license sanctions?

JC, NCQA, HFAP

Malpractice coverage is necessary for what accreditation systems?

NCQA, HFAP, URAC

Who uses five year history for evaluation of malpractice?

NCQA, HFAP

What is the accepted time limit of malpractice history for URAC?

6 Months

What is the verification time limit for medicare sanctions for NCQA?

180 days

Who has provisional credentialing?

NCQA, URAC

Who has temporary privileges?

JC, HFAP

Who requires peer recommendations?

JC, HFAP, AAAHC

Does NCQA use credentialing committee to make recommendations?

Yes

Can HFAP use credentialing committee to make recommendations?

Yes

Does JC require work history verification?

No

Who on initial appointment review work history for continuity and relevance?

AAAHC

Who requires that all licensed independent practitoners must be credentialed and privileged through the organized Medical Staff structure?

JC

NCQA current licensure verification time limit of CVO?

120 days

NCQA malpractice verification time limits for CVO?

120 days

NCQA time limits on professional liability / malpractice for CVO?

Must be current, valid and verified within 305 calendar days prior to submission to each client

What is the main reason for periodically assessing appropriateness of clinical privileges for each specialty?

To protect patient safety by ensuring current competency, revelance to the facility and accepted standards of trade.

Telemedicine originating site is?

Site where the patient is receiving care is located

This legislation prohibits a physician with a financial arrangement with an entity from referring Medicare or Medicaid patients to that entity.

Stark Law

Verification time limit for licensure per NCQA CVO standards?

120 days

Per NCQA standards on initial applications, review of information on sanctions, restrictions, on licensure and limitations on scope of practice must cover what period of time?

The most recent 5-years

In the MCO, a review board or Governing Body may review a credentialing decision after the Credentialing Committee approval. What date does the NCQA use when assessing performance against timeliness requirements for PSV?

Decision date of the Credentials Committee

JC approved designated sources for verification against a physician's medical license?

FSMB, State Medical Boards

This federal law was enacted for the purpose of encouraging good faith professional review activities:

Health Care Quality Improvement Act of 1986 (HCQIA)

At reappointment NCQA requires 4 factors within prescribed time limits:

1. DEA or CVS


2. Board Certification


3. Liability Claims, settled or judgments


4. Licensure

What are the CMS criteria for selection to the medical staff?

Competency

Character


Judgment


Experience Training


NCQA requires these factors prior to provisional credentialing?

Current license


Past 5 years of claims, settlements or NPDB report


Application with signed attestation

AAAHC requires recredentialing every 3 years except for:

When state regulations require less time

AAAHC requires PSV of the following elements upon initial application:

Experience reviewed including gaps


Peer evaluation


Liability insurance


NPDB


education, training experience


current state license


DEA



What is the verification time limit for licensure per NCQA CVO Standards?

120 Days

Who requires participation in CME be considered in decisiions about reappointment to membership on the medical staff or renewal or revision of individual clinical privileges?

JC

Does JC consider CME in decision making at initial appointment?

No

According to NCQA standards, on initial application, review of information on sanctions, restrictions on licensure and limitations on scope of practice must cover what period of time?

Most recent five year period

CCJET

Competence


Character


Judgment


Experience


Training

URAC standards require PSV of what two elements when it initially credentialing a provider.

State License


Highest level of education



URAC Standards require The organization to provide written notification to providers within how many calendar days of the credentialing determination?

10 Days

In regards to the credentialing process, NCQA standards require the organization to have written policies and procedures to delineate a practitioners rights. These include:

1. The right to review information submitted to support the credentialing application.


2. Right to correct erroneous information


3. Right to receive notification of these rights


4. Right to receive status application upon request

When credentialing, NCQA requires the organization to verify four factors that can prescribe time limits. What are they?

1. DEA


2. Board certification


3. History of professional liabilities resulting in settlement


4. Licensure

CMS conditions of participation for hospitals require that criteria for selection to the medical staff include evaluation of five areas:

1. Character


2. Competence


3. Training


4. Experience


5. Judgment

NCQA requires verification of which three factors prior to provisionally credentialing a provider?

PSV current license


Past five years malpractice or NPDB


Current signed application with attestation

AAAHC standards require PSV of a number of elements on initial application. Name them:

1. Education


2. Training


3. Experience


4. Current state License


5. DEA


6. NPDB


7. Peer references


8. Experienced review


9. current malpractice insurance

What is EMTALA

Emergency transfer and active labor act or Federal antidumping law.



What is the purpose of EMTALA

To prevent hospitals transferring, discharging, or refusing to treat indigent patients coming to the emergency department because of cost factors.

Are medical malpractice payors required to query the NPDB?

No

Name two sources of verification of education of a chiropractor according to NCQA?

1. Chiropractice college


2. State Licensing Agency

According to URAC what must be verified using PS?

State Licensure


highest level of education

According to NCQA what verificatin is required before provisional credentialing is permitted?

1. Current licensure


2. 5 year malpractice history

NCQA requires applicants to confirm good health & competence to perform essential functions. How is this achieved?

Signed attestation

Within how many days must a medical malpractice payor report payment resulting from written claim or judgment to the NPDB & state licensing board?

30 days

What is the verification time limit for verification of Medicare/Medicaid sanctions according to NCQA?

180 days

What came first, NPDB or HIPDB?

NPDB

According to NCQA, how long is the signature on the attestion good for?

365 days

According to NCQA how long is the signature on the attestation good for, for the CVO's?

305 days

According to URAC who should oversee the clinical aspects of the credentialing program within the organization?

The Senior clinical staff person

Name 3 sources of verification of education of a dentist according to NCQA?

1. Dental School


2. Specialty Board


3. State Licensing Board

NCQA requires MCO's to recredential practitioners every:

3 years

What six criteria are observed in an initial site visit by NCQA?

1. Physical accessibility


2. Physical apperance


3. Adequacy of waiting and exam rooms


4. Appointment availability


5. Adequacy of treatment


6. Record keeping processes

According to JC what should be used to verify current competence?

Hospital verification

According to NCQA who has ultimate authority in credentialing decisions?

Credentials committee or medical director if it is clean file

Name the six general competencies according to the ACGME & ABMS

1. Patient care


2. Medical/Clinical knowledge


3. Practice based learning and improvement


4. Interpersonal & communication skills


5. Professionalism


6. System based practice

According to NCQA application, PSV must be dated within ????? days of the credentialing decisions?

180 days

According to NCQA what credential must be verified at the time of recredentialing?

Current malpractice


State Licensure

According to NCQA, how long is the board certification good for?

180 days

Professional societies must report adverse actions or payouts within how many days to the NPDB?

15 days

Hospitals and healthcare entities must report adverse actions within how many days to the NPDB?

15 days

State Licensing board must report adverse actions within how many days to the NPDB?

30 days

Malpractice payors must report adverse actions or payouts within how many days to the NPDB?

30 days

Name 3 sources of verification of education of a podiatrist according to NCQA?

1. School


2. Specialty board


3. State Licensing agency

DEA Registration: High abuse Potential - No medical Use

I

Which JC terminology references the new and revised elements of the accreditation and survey process?

New pathways

According to NCQA a set of standardized measures used to compare health plans is???

HEDIS

NCQA grants a CVO certification of a period of?

2 years

The medical staff is actively involved in measuring, assessing, and improving what?

Patient safety data

DEA: High abuse potential with dependence liability

II

Who/what is the highest level of authority for URAC?

The Credentials Committee -


May delegate "clean" applications to Senior clinical staff person"

DEA: Less abuse potential, moderate dependence?

III

What is a committee of the whole?

The medical staff as a whole carries out the governance functions.

When did the organized medical staff get it's start?

1917

Who published the "Hospital Standards"?

American College of Surgeons

Per NCQA Standards what is the time limit for provisional credentialing?

60 days

According to HFAP standards temporary privileges may be granted in what cases?

1. For time of emergency or disaster


2. Locum tenens


3. During review and consideration of application


4. For care of specific patients

Per URAC Standards, who has final authority to approve/disapprove applications?

Credentials Committee

EMTALA

Emergency Treatment and Active Labor Act

According to URAC how is the recredentialing cycle calculated?

MM/YY to MM/YY

According to URAC, who should oversee the clinical aspects of the credentialing program within the organization?

Senior Clinical Staff person

What federal system is a list of individuals and firms excluded by Federal government agencies from receiving federal contracts or federally approved subcontracts and from certain types of federal financial and nonfinancial assistance and benefits?

EPLS

What is Statuary Law?

Legislation passed by democratically elected state legislatures and federal congress

DEA: Less abuse potential, limited dependence

IV

In what circumstances does JC permit the granting of temporary privileges?

1. To fulfill an important patient care need


2. When a new applicant with a complete, "clean" application that raises no concerns is awaiting review and approval of the medical executive committee & board

Privileged motions include:

1. Adjourn


2. Recess


3. Question of privilege

According to NCQA Standards, a copy is acceptable certification of the document:

Medical School Diploma

Which accreditation bodies have standards for medical record documentation and confidentiality?

JC, NCQA

Subsidiary motions include:

1. Lay on the table


2. Previous question (end debate)


3. Commit or refer (committee)

According to NCQA, the timeframe within which the DEA verification is permitted is:

No timeframe, must be current at the time of credentials committee review

According to URAC, PSV or secondary PSV may not be collected:

More than 6 months prior to Credentialing Committee

Does NCQA require Locum Tenens to be credentialed when working in an independent relationship within the inpatient setting?

No

NCQA requirements for Professional Practice Questions include:

1. The correctness and completeness of the application


2. Current malpractice coverage


3. Lack of present illegal drug use

JC requirements for Professional Practice Questions:

Voluntary and involuntary limitation, reduction or loss of clinical privileges

NCQA requirements for delegated credentialing are permitted under a written delegation document that includes:

1. Be mutually agreed upon


2. Describe the delegated activities


3. Describe the responsibilities of the organization and the delegated entity

According to URAC, no credentialing application may be accepted if it is signed and dated more than:

180 days prior to Credentialing Committee review

Which of the following specifically require an attestation

1. NCQA


2. URAC


3. AAAHC

Who allows credentialing information from another healthcare organization such as a hospital or group practice to be accepted for credentialing?

AAAHC

The Medicare Conditions of participation are contained in what federal regulation?

Code of Federal Regulations

DEA: Limited abuse potential

V

According to NCQA Standards, which credential MUST be obtained at the time of credentialing?

Current malpractice insurance certificate

Which accrediting bodies require a process to address complaints?

JC


NCQA


HFAP


URAC


CMS

According to JC what document may be obtained to verify current competence?

Hospital verification

Per JC what must decisions on membership and granting of privileges consider?

Criteria directly related to the quality of healthcare, treatment ad services

Motions are ranked in the following order:

1. Privileged


2. Subsidiary


3. Main

HIPPA regulations are divided into four Standards or Rules:

1. Security


2. Identifiers


3. Transactions and Code Sets


4. Privacy

A main motion:

Brings an item of business to the body for consideration

CMS criteria for selection to the medical staff:

CCTEJ


Character, competence, training, experience, judgment

According to NCQA requirements, the verification time limit for work history is

365 calendar days for Health Plan


305 calendar days for CVO


MA deeming surveys 180 calendar days

Per NCQA the following must be verified at time of recredentialing:

1 LIcense


2. DEA


3. Board Certification


4. Medicare/Medicaid Sanctions


5. Malpractice claims

Who specifically requires peer References?

1. JC


2. HFAP


3. AAAHC

Who requires a statement by the applicant regarding felony convictios?

1. NCQA


2. HFAP


3. AAAHC

What is the purpose of the Stark Law?

To prohibit a physician who has a financial relationship with an entity from referring Medicare or Medicaid patients to that entity for the provision of a designated health service

Why was the HIPDB created?

To combat fraud and abuse in health insurance and healthcare delivery and to promote quality care

Joint commission define credentialing as
The process of obtaining, verifying, and assessing the qualifications of a health care practitioner who seeks to provide patient care in or for a hospital
NCQA defines credentialing as
A process by which an organization reviews and evaluates qualifications of licensed independent practitioners to provider services to its members.
The three main reasons for credentialing are
1. Patient Safety2. Risk Management concerns3. Required by accrediting and regulatory agencies
What does CoPs stand for
Medicare Conditions of Participation - The CoPs are contained in the code of federal regulations are intended to protect patient health and safety and to ensure quality of care for hospitalized patients

Why get accredited

Accreditation assists organizations in monitoring and improving quality of care. It can be used to meet certain Medicare certification requirements, organizations that are accredited are given "deemed status" meaning they meet the Medicare and Medicaid requirements for participation.
Other reasons to become accredited
1. may favorably influence liability insurance premiums2. may be required in order to obtain managed care contracts3. Employers and unions may require accreditation for providing health care coverage to employees
After CMS approves an Accreditor they are given deemed status, name the accreditors that have deemed status
1. The joint commission TJC2. American Osteopathic Association Health Facilities Accreditation program (AOA-HFAP)3.Det Norske Veritas Healthcare Inc. (DNV)4. National Integrated accreditation for healthcare organizations (NIAHO)5. National committee for quality assurance (NCQA)6. URAC7. Accreditation association for ambulatory health care (AAAHC)
What is Compliance
Participate in the development, implementation, an ongoing assessment of bylaws, rules and regulations, policies & procedures to ensure continuous compliance with accreditation regulatory standards.
What is the MSO
Medical Staff Organization - although various regulatory agencies & Accreditation bodies require certain organizational components, the formal structure and specific operational mechanisms are at the discretion of the MSO and governing body of the healthcare organization
What are the functions of the MSO
Providing patient care, evaluation the quality of patient care, maintenance of the MSO.
What is the medical staff
It is a self governing entity which exists as an extension of the healthcare facility
How is the medical Staff structured
the organizational structure of the medical staff as delineated in it's bylaws defined the framework within which medical staff appointees act and interact in hospital related activities.
Bylaws - why are they written
Bylaws are written to conform to generally accepted guidelines for broad content categories - they ensure compliance with legal requirements and accreditation and regulatory agencies.
Why review your bylaws
bylaws are reviewed and appropriate amendments are essential to keep up with changes in accreditation standards and regulatory requirements
How often should your bylaws be reviewed
Typically MSO's make provisiton for at least a biennial review of the bylaws.
Bylaws committee - purpose
the purpose of the bylaws committee is to review the bylaws and to make recommendations to the medical staff's executive committee (MEC)
When do bylaw changes go into effect
bylaw changes are adopted by majority vote of the medical staff. Bylaw changes are not effective until approved by the governing body.
What should be included in your bylaws
Bylaws should include all items necessary to provide a basic frame work for the MSO and to fulfill requirements of the law, regulatory agencies, and accreditation bodies. Also some states have specific requirements for elements to be included in bylaws.
Detail what medical staff appointees may or may not do. such as requirements for specific clinical processes, rules of each clinical department, requirements for ER coverage, guidelines for obtaining consultation, membership dues, provisions for leave of absence, medical records completion, community call coverage requirements, meeting attendance, and other staff responsibilities and prerogatives.
Rules and Regulations -
How can changes be made for rules and regulations for individual departments
the medical staff may delegate the authority for changing the rules and regulations to the MEC.
describe the course of conduct or action pursued or the management of a matter in certain circumstances. Policies are often used to address internal matters and may be subject to frequent change. The medical Staff may delegate the authority for changing the rules and regs to the MEC.
Policies and Procedures -
Why should MSP's be familiar with the regs and accreditation standards that apply to their organization?
It is a good idea to audit bylaws, rules, regs, and policies to make sure that they comply with state regs and accreditation standards.
What if you find out you are not compliant with your bylaws?
You should determine the basis for the bylaw requirement, if it is not required by accreditation standards, state of federal regs, confer with your legal counsel as to whether not to change the bylaws to reflect your current practice.
Instead of Bylaws what do MCO's use?
MCO's use policies and procedures to delineate required functions.
Who gets credentialed
Hospitals governing body and medical staff define medical staff membership criteria in the bylaws.
NCQA describes credentialing as-
The process by which the managed care organization authorizes contracts with or employs clinicians who are licensed to practice independently to provide services to it members.
Who do the credentialing standards apply to?
They apply to all licensed practitioners or groups of practitioners who provide care to the organizations members
What criteria must the bylaws include to meet CoPs requirements
Your bylaws must describe the qualifications required of a candidate in order for the medical staff to recommend appointment by the governing body.
Main Motion
This motion introduces items to membership for consideration and cannot be made when any other motion is on the floor.
Subsidary Motion
This motion changes or affects how a main motion is handled. Subsidary motion is voted on before a main motion.
Call for Order of the Day
A request to follow the agenda
Privileged motion
This motion brings up items that are urgent - unrelated to pending business. Take precedence over all other motions.
A motion to divide the assemble
A more exlicit type of vote (show of hands)
Incidental motions
Resolve particular questions that arise in connections with the assembly's conduct of business. They take priority over main motions.
Incidental motions include
10 things - Objection To Considerations, Point Of Order, Request For Information, Parliamentary Inquiry, Request To Withdraw A Motion, Motion To Determine Manner Of Voting, Request For Division Of A Question, Request For Division Of The Assembly, Appeal Of A Ruling From The Chair, And Motion To Suspend A Rule
Main Motions
Bring an item of business to the assembly for consideration.
Negligent Tort has 4 elements, what are they?
1. Duty to exercise due care: standard of care, 2. Breach of duty, 3. Injury (no injury - no liability), 4. Proximate Cause: injury must be caused by breach of duty
Recall motions
To correct inadvertent errors, reexamine actions on proposals and reverse them. 2 types of motions.
Secondary Motions
Facilitate the discussion of main motions and are divided into privileged, subsidiary, incidental, and recall motions.

Requirements for appointment are called:

criteria - reflective of education, training current competence, health status, and licensure

External Criteria

Set by forces outside the organization, accrediting & certifying bodies such as JC, NCQA, state and federal regulations such as CMS.

Internal Criteria

Defined by the hospitals medical staff and governing board of the MCO's board

Does MCO's utilize Bylaws?

No, MCO's use polices and procedures to delineate required functions

What do Rules and Regulations describe?

What medical staff appointees may or may not do

What do policies and procedures describe?

The course of conduct or action pursued or the management of a matter in certain circumstances

The medical staff may delegate the authority to whom for changing the rules and regulations?

The MEC

Reasons for credentialing

Patient Safety


Risk Management concerns


Required by Accrediting and Regulatory Agencies

Where are COP's are contained:

Code of Federal Regulations

Who Gets Credentialed?


Hospitals Credential:

All hospital accreditation standards require the medical staff membership criteria be defined in the medical staff bylaws in compliance with state regulations. The hospital may choose to allow both licensed independent practitioners and other non-independent practitioners appointment to the medical staff.

Who Does NOT get Credentialed?


NCQA

Those who practice exclusively within the inpatient setting


Those who practice exclusively within free-standing facilities


Pharmacists working for a pharmacy


Locum tenens (unless working for longer than 90 days)


Rental network practitioners

Who Gets Credentialed?


URAC

The organization verify the professional qualifications of all participating providers as well as facilities that provide covered health care services to consumers. All practitioners listed in the directory must be credentialed.

Who Gets Credentialed?


Ambulatory Care Facility

AAAHC requires that the governing body defines criteria for the initial appointment and reappointment of physicians and dentists. They do NOT specify which providers need to be credentialed.

Minium criteria for appointment to the medical staff/granting of medical staff privileges include:

C: Character


C: Competence


T: Training


E: Experience


J: Judgment

NCQA Attestation addresses the following:

Reasons for any inability to perform the essential functions of the position, with or without accomodation


Lack of present illegal drug use


History of loss of license and felony convictions


History of loss or limitation of privileges or disciplinary activity


Curren malpractice insurance coverage


The correctness and completeness of application

HFAP application requests information regarding the following:

Disciplinary actions taken or investigations pending by hospitals or other healthcare facilities, specialty boards, Medicare/Medicaid


Actions against DEA


Actions listed in the NDB


Information regarding criminal history

JC evaluates the following information before granting privileges:

Challenges to any licensure or registration


Voluntary & involuntary relinquishment of any license registration


Voluntary & involuntary termination of medical staff membership


Voluntary & involuntary limitation, reduction, or loss of clinical privileges


Any evidence of unusual pattern or an excessive number of professional liability actions resulting in a final judgment against the practitiners

URAC applications includes:

History of sactions


loss or limitation of privileges or disciplinary activity


Disclosure of any physical mental or substance abuse problems which without reasonable accomodation impede the practitioners ability to provide are according to accepted standards

AAAHC organization requires information upon application regarding:

Information concerning complaints or adverse actions by a professional society, licensure board, licensure disciplinary actions, refusal of professional liability coverage, criminal convictions other than minor traffic violations, Medicare/Medicaid sanctions, current physical/mental health, and chemical dependency problems

NCQA Edcation verification time limit:

None

URAC Education verification time limit:

6 Months

URAC verification of Training time limit:

6 Months

Medicare certfiied ASC's

Who requires the ASC's to have either a written transfer agreement with a hospital or to ensure that all physicians performing surgery in the ASC have admitting privileges at a nerby Hospital?

When must ASC's verify admitting privileges

When they are Medicare Certiied

How many member boards and specialties and subspecialties does the ABMS have?

24 Member Boards


145 Specialties & Supspecialties

NCQA Verification time limit for Work History:

365 Calendar days for Health Plan


305 Calendar Days for CVO


180 Days for Medicare Advantage deeming surveys

NCQA Verification time limit for Board Certification:

180 days


120 days for CVO

Does NCQA require verification of Board Certification?

If the practitioner claims to be board certified, the organization must verify it.

Does NCQA require verification of Board Certification at reappointment?

Yes, if the certification has expired or if additional certification has been added

Does URAC require verification of Board Certification?

Verify Board Certification if this is the highest level of education.


What is the time limit for verification of Board Certification for URA?

6 Months

When does AAAHC require verification of Board Certification?

At initial application and ongoing basis.

Verification time limit for Licensure according to NCQA

180 days


120 days for CVO

Verification time limit of DEA according to URAC

6 Months

Verification time limit of Malpractice Insurance coverage according to NCQA

180 Days


120 Days

What prohibits unlawful employment discrimination based on race or color, religion, gender and national origin?

The Civil Rights Act of 1871

Nondiscrimination according to JC

Consideration of gender, race, creed, or national origin cannot be used in making privileging decisions

Nondiscrimination according to HFAP

Membership critieria cannot include sex, race, creed, national origin, or handicap cannot be impact the applicant's ability to discharge privileges for which were applied

Nondiscrimination according to NCQA

Policies and procedures must explicitly state the steps that the organization takes during the credentialing/recredentialing processes to monitor for and prevent discriminatory practices

Nondiscrimination according to URAC

Credentialing program includes a statement that the organization will not discriminate against providers

Nondiscrimination according to AAAHC

Not addressed

Medicare/Medicaid Sanctions/Exclusions:


Requirement by JC

Not addressed

Medicare/Medicaid Sanctions/Exclusions:


Requirement by HFAP

Sanctions or disciplinary actions must be reviewed at initial & reappointment.


The application requests information regarding disciplinary actions taken or investigations pending by Medicare/Medicaid.

Medicare/Medicaid Sanctions/Exclusions:


Requirement by NCQA

Organizations are responsible for ongoing monitoring of Medicare/Medicaid sanctions between recredentialing cycles.

NCQA requires a query of Medicare/Medicaid Sanctions by a query from:

Federal Employees Health Benefits Plan


FSMB


NPDB/HIPDB


List of Excluded individuals and entities (maintained by OIG)


Medicare and Medicaid Sanctions and Reinstatement Report


State Medicaid agency or Medicare Intermediary

Medicare/Medicaid Sanctions Exclusions:


Requirement by URAC

Required to be reported on application

Medicare/Medicaid Sanctions Exclusions:


Requirement by AAAHC

Disclosed and evaluated on initial and reapplication

What is Current Competence?

A determination of an individual's capability to perform up to defined expectations

Current competence is determined by the JC how?

Through peer references


It is recommended but not required that hospitals base evaluations on the six areas of General Competencies adopted by ACGME and ABMS

Current competence is determined by HFAP how?

Information obtained from residency or facilities where the applicant has been practicing


Low volume may require review of procedure logs and competency from other facilities

Current competence is determined by NCQA how?

Not addressed

Current competence is determined by URAC how?

Not addressed

Current competence is determined by AAAHC how?

On initial application. Obtained from peers

Attestation time limit for NCQA:

365


305 For CVO

Attestation time limit for NCQA Medicare Advantage Deeming Surveys:

180


120 for CVO

Which accreditation standards address consent and release for credentialing?

None

The release form should permit release of:

1. Professional evaluations


2. Information from Insurance Carriers


3. Information from hospitals licensure boards, certification boards, insurance plans, etc.