CAMSS 42 nd Annual Education Forum

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1 CAMSS 42 nd Annual Education Forum Speaker: Veronica Harris, QM Project Manager, Aetna. Inc. Date: Wednesday, May 29, 2013 Time: 1:45pm 3:15pm Managed Care Credentialing Complexities Topics: Locums and how they fit into the managed care world Hospital based provider why you may want to credential them Information on how to and why Health Delivery Organizations (HDOs) are credentialed 1

2 Session Topics Locum tenens and how they fit into the managed care world Who are they? What do they do? How do they fit in? Hospital based provider why you may want to credential them Who are they? Who is responsible for the credentialing? Information on how to and why HDOs are credentialed What are HDOs Credentialing Requirements Accrediting Bodies Site visit requirements for Non-accredited HDOs 2

3 Locum Tenens and How They Fit Into The Managed Care World? What is a Locum Tenens and what do they do? A temporary physician that covers or substitutes for a regular physician during their absence from practice. (vacation, medical leave, sabbatical, childbirth, leaving the practice, etc Work as an independent contractors of physicians, medical groups, agencies or other healthcare facilities to perform medical services over a certain period of time. Most common specialty types: Emergency Medicine, Family Practice, General Practice, Hospitalist, Internal Medicine, OB/GYN, Occupational Medicine, Pediatric, Radiology, Surgical Specialties, Urgent Care 3

4 Locum Tenens and How They Fit Into The Managed Care World? How long can physicians serve as a locum tenens? A single locum tenens physician cannot cover for more than 60 continuous days for Medicare unless there is a break in the calendar by a regular physician. (Except for physicians who are called to active duty in the armed forces) If a regular physician requires that the locum tenens physician provides services for longer than 60 continuous days without a break, the locum tenens physician must enroll with the practice. 4

5 Locum Tenens and How They Fit Into The Managed Care World? Role of Locum Tenens Agencies: Credentialing Services Professional liability insurance Screening of the locum tenens, taking the liability and burden off practices and healthcare organizations Some agencies are certified by the Join Commission 5

6 Locum Tenens and How They Fit Into The Managed Care World? How do Locums fit in? Benefits of utilizing a locum physicians To fill in for an absent staff member (who may be ill, on vacation, on sabbatical or maternity leave) To cover while staff physicians attend CME courses To supplement permanent staff during busy times To staff new positions or facilities while physicians are recruited 6

7 Hospital-Based Practitioners And Who Is Responsible For Credentialing What are hospital based / facility based practitioners? Practitioners who practice exclusively within a inpatient/hospital setting or free-standing facility and who provide care for members only as a result of being directed to the inpatient/hospital setting or facility. Practitioners are not listed in directories. Most common specialty Types: radiologists, pathologists, emergency room physicians, anesthesiologists, hospitalists, neonatologists, intensive care physicians and behavioral health care practitioners. Facilities where services are provided that are not physically located within a hospital. Examples include, but are not limited to: urgent care centers, surgical centers, birthing centers, mammography centers, cardiac catheterization labs and radiology centers. 7

8 Hospital-Based Practitioners And Who Is Responsible For Credentialing Who is responsible for credentialing? Why you may want to credential? 8

9 Health Delivery Organizations (HDOs) Medical Providers Free-standing surgical centers Hospital Home health agencies Skilled nursing facilities (SNF) Inpatient Residential Ambulatory Behavioral Health Providers Behavioral Health Organizations include, but are not limited to: mental health and chemical dependency hospitals, residential treatment facilities and ambulatory settings including, Partial Hospital Programs, Intensive Outpatient Programs, Crisis Stabilization Centers, and clinics and Community Mental Health Center. 9

10 Health Delivery Organizations (HDOs) Medicare/CMS Providers and Suppliers Ambulatory surgery centers Hospital Home health agencies Skilled nursing facilities and/or nursing homes Clinical laboratories Comprehensive outpatient rehab. facilities (CORF) End-stage renal disease services providers Federally qualified health centers (FQHC) Hospices Outpatient diabetes self-management training providers Outpatient physical therapy providers Portable x-ray suppliers Rural health clinics (RHC) Speech pathology providers 10

11 Health Delivery Organizations (HDOs) Credentialing Requirements Prior to contracting with a provider and for at least every 3 years thereafter and organization must: 1. Confirms that the provider is in good standing with state and federal regulatory bodies. 2. Confirms that the provider has been reviewed and approved by an accrediting body. 3. Conducts an on-site quality assessment for non-accredited providers. 11

12 Health Delivery Organizations (HDOs) Assessment of Providers 1. Confirmation of good standing: State Regulatory Bodies Current unencumbered state license/certification or certificate of occupancy Federal Regulatory Bodies Good standing with Medicare and Medicaid/Medi-Cal, as appropriate, i.e., the Organizational Provider is not on Office of Inspector General (OIG) sanctions or other federal agency. 2. Reviewed and approved by an accrediting body: Accreditation Certificate or Letter 12

13 Health Delivery Organizations (HDOs) Assessment of Providers 3. Site visit, for non-accredited providers (Within 3 years of verification) If an organizational provider is not accredited, an organizations must conduct an onsite quality assessment. The organization must develop a selection process and assessment criteria for each type of non accredited provider. The process must include a process for ensuring that the provider credentials its practitioners. develops and implements standards of participation, including conducting a site visit. 13

14 Health Delivery Organizations (HDOs) Assessment of Providers Additional areas of assessment may include: Environmental Review (Appearance/Cleanliness, Accessibility, Equipment Maintenance) Administrative Requirements (Disaster Plan, Job Descriptions, Policy and Procedures for: Patient Assessment, Admission, Discharge Planning, Case Management, Transfers, etc.) Quality Assessment Review (Written QA/QI Plan, Chart Review, Participation in the QA Program, Evaluation or QA Activities) Administrative Information (Ratings: Admissions, Occupancy, Re-admits, etc.) CMS or State reviews may be used in lieu of the required site visit. 14

15 Organizational Provider Spreadsheet Provider / Facility Name Provider /Facility Type Prior Validati on Date/ License Status Prior Accredit ation Validati on Date/Bo dy/ Status Prior Site Visit Date Prior Revie w/ Appro val Date Current Validati on Date/ License Status Current Accreditat ion Validation Date/Bod y/ Status Curre nt Site Visit Date Current Review Date- Medicare and Medicaid Sanction s Report Medicare Certificat ion Number (as appl.) Current Review/ Approval Date Delta Hospital Hospital 5/15/10, Active 5/15/10, JTC, Active 05/19/ 10 05/19/ 10 04/03/13, Active 04/03/13 JTC, Active NA 04/15/ /30/13 Clinical Lab Assoc Clinical Lab 07/25/09, CLIA, Active NA NA 07/27/ 09 05/12/12, CLIA, Active NA NA 05/12/ /24/12 ABC Home Health Home Health 10/10/07, Active 10/10/07, ACHC, Active NA 10/15/ 07 10/25/10, Active 1008/10, ACHC, Active NA 10/15/ /27/10 Cross Surgery Surgery Center 3/15/08, Active NA 3/5/07, DHS 03/20/ 08 3/15/11, Active NA 02/05/ 10DH S 03/20/ /24/11 15

16 Accrediting Bodies by Provider Type Hospitals The Joint Commission (TJC) Healthcare Facilities Accreditation Program (HFAP), accrediting program approved by the American Osteopathic Association (AOA) Det Norske Veritas National Integrated Accreditation for Healthcare Organization (DNVNIAHO) Home Health Agencies The Joint Commission (TJC) Community Health Accreditation Program (CHAP) Accreditation Commission for Health Care Inc. (ACHC) Free-Standing Surgical Centers The Joint Commission (TJC) American Association for Accreditation of Ambulatory Surgical Facilities (AAAASF) Accreditation Association for Ambulatory Health Care (AAAHC) Healthcare Facilities Accreditation Program (HFAP) 16

17 Accrediting Bodies by Provider Type Skilled Nursing Facilities The Joint Commission (TJC) Commission on Accreditation or Rehabilitation Facilities (CARF) Continuing Care Accreditation Commission (CCAC) Behavioral Health Providers (Intensive Outpatient Programs and Residential Treatment Programs) The Joint Commission (TJC) Commission on Accreditation or Rehabilitation Facilities (CARF) Healthcare Facilities Accreditation Program (HFAP), accrediting program approved by the American Osteopathic Association (AOA) Council on Accreditation (COA) 17

18 Accrediting Bodies by Provider Type Clinical Laboratories Clinical Laboratory Association Improvement Amendments (CLIA) Certificate or CLIA Waiver Commission on Office Laboratory Accreditation (COLA) Comprehensive Outpatient Rehabilitation Facilities The Joint Commission (TJC) Commission on Accreditation or Rehabilitation Facilities (CARF) Hospice The Joint Commission (TJC) Community Health Accreditation Program (CHAP) Outpatient diabetics self-management training providers American Association of Diabetes Educators (AADE) Indian Health Service (IHS) 18

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