CREDENTIALS VERIFICATION ORGANIZATION & COMPLIANCE

Sanctions Monitoring and Reporting

Sanctions are disciplinary actions imposed against licensed providers and can have far-reaching consequences. OIG guidelines clearly state that healthcare organizations cannot employ sanctioned or excluded individuals. If an organization fails to disclose any excluded providers employed, the organization can be fined upwards of $100,000 per excluded employee. Now, more than ever, it is exceedingly important for organizations to take proper action to monitor their providers for sanctions and exclusions.

Catalyst Consulting helps healthcare organizations maintain compliance by identifying through The Office of the Inspector General: U.S. Department of Health and Human Services (OIG), The General Services Administration (GSA), and The Department of the Treasury (OFAC), on a monthly basis, providers who have been sanctioned or excluded from participation in state and federal healthcare programs. Potential matches are investigated by Catalyst and results are returned to your organization immediately for processing.

 

Expiring Document Management

Expiration dates of time-sensitive credentials are monitored and updated on an on-going basis. Reminders are sent to providers on a client customized timeline. (120, 90, 60, 45, 30, 15-day marks are all options.)

• Primary State license

• DEA License

• CSR

• Malpractice Insurance

• Board Certification

• CPR

• Driver License

• CSR License

• Hospital Reappointment Dates- No limit to hospitals tracked.

• And many more, as required

 

Delegated Credentialing Assistance

Delegated credentialing helps health plans reduce turnaround time for network participation and enables them to manage a higher volume of providers to accommodate network growth. Also, delegated credentialing supports contracting efforts and ultimately increases provider satisfaction. The benefits of delegated credentialing from a medical group practice’s perspective are many. First and foremost, with delegated credentialing you may eliminate weeks in the provider enrollment process. A reduced turnaround for network participation means timelier reimbursement from payers. Depending on the terms of your agreements and how many you manage to put in place, you may also be able to greatly reduce the amount of time and resources dedicated to provider enrollment. Finally, delegated credentialing increases both provider and patient satisfaction as your new providers can rapidly put their expertise to work and your patients benefit from that care.

 

Most health plans are eager to delegate more of the credentialing work to provider groups, but before they will agree to delegate, you must have a robust ‘in-house’ credentialing process in place – one that works relevant accreditation requirements into your policies and procedures and operationalizes them.

 

Catalyst will perform the following steps and provide guidance in setting up your fully compliant credentialing program that ensures the proper infrastructure, resources, and personnel are in place to support the credentialing function and become delegated:

 

• Evaluate current credentialing program and determine how to proceed going forward for best practices.

• Create credentialing processes based on the evaluation.

• Set up processes, policies and procedures based on NCQA Standards and Guidelines, incorporating payors and state requirements.

• Assist in set up of framework for a credentialing committee to review provider credentials and make credentialing recommendations.

• Submit requests with each payor to become delegated.

• Work with each payor when performing evaluation of practice’s ability to perform credentialing tasks.

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NCQA Accreditation Assistance

Catalyst Consulting will assist with review and follow through of all necessary components for Client to secure NCQA Status. Catalyst will start by reviewing the NCQA Standards for CR Accreditation and assessing the readiness of the organization to apply. Based upon the readiness, we will develop a plan to address the most complex issues and identify key vulnerabilities or gaps. Catalyst will perform file audits and conduct mock surveys to identify any gaps in compliance, and work with the organization to correct any issues to prepare for a successful audit. Once all areas have been reviewed and addressed and are in compliance, Client will be able to set a readiness date for an on-site survey.

 

NCQA bases results on clinical performance and consumers' experience. Catalyst will work with Client to assist with reviewing Client’s current bylaws, policies and procedures to meet standards encompassing more than 100 measured elements. The accreditation helps guarantee that the organization delivering care and making decisions is following objective, evidence-based best practices. Catalyst will assist with evaluating operational standards the organization is following and verify that required operational structure is in place. Catalyst will also verify that the organization satisfies state requirements for accreditation.

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Medical Staff Governing Documents - Development of Bylaws, Policies & Procedures

Policies and procedures along with bylaws fall under the umbrella of governing documents. The medical staff or organization is not only responsible for creating but revising, following, and enforcing. It is imperative for bylaws and policies and procedures to align; if conflicting, the organization can open itself up to lawsuits and can create negativity in the medical staff culture by not giving physicians clear guidelines to follow.

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Catalyst will assist medical staff leaders and professionals develop clear and thorough policies and procedures and bylaws for their organizations that comply with their accreditors’ requirements and promote industry best practices. Policies and Procedures will follow the corresponding Bylaws established.

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Bylaws will address the preliminaries, medical staff governance and organizational structure, member rights with corrective action and fair hearings, credentialing and privileging procedures, allied health professionals and medical staff operational issues. Policies and Procedures will address the administration, credentialing and privileging, governance and quality.

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Organizations adopt bylaws for the governance of their members and the management of their affairs. An organization's bylaws should outline its administrative structure, how decisions will be made at high levels, and the mechanism for adopting and amending governing documents. Note: Medical staff that must comply with Joint Commission standards will require much more detailed bylaws than staff accredited by other entities.

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Whenever crafting bylaws, it is prudent to examine whether a specific issue can be addressed more effectively through medical staff policies and procedures. Because medical executive committees (MECs) can modify medical staff policies more quickly, they are more flexible and adaptable. A topic or matter that is likely to remain stable over time should be considered for inclusion in bylaws. Structures, issues, and processes that are likely to change frequently should be addressed in policy form. These policies are often compiled by medical staff and categorized by topic in manuals. A "Credentials Policy and Procedure Manual," for example, explains how credentialing should work or outlines how committees should work.

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When reviewing the language in bylaws, medical staff leaders frequently defer to previously published model bylaws that may, in fact, no longer reflect current needs and concepts. So it's important to investigate if the older bylaws’ construction, format, and content continue to be practical and efficient.