Credentialing

The existing standard CR 17 for both Health Plan and Health Network reads:

The organization complies with the Core Standards for any credentialing functions it delegates to another entity. In addition, the organization: (Secondary)
(a) Retains authority to make the final credentialing determination regarding any provider; and (Primary)
(b) At least every three years, conducts surveys of each entity that performs credentialing functions on behalf of the organization. (Secondary)

The proposed revision would change (b), leaving the standard to read:

The organization complies with the Core Standards for any credentialing functions it delegates to another entity. In addition, the organization: [--]
(a) Retains authority to make the final credentialing determination regarding any provider; [M]
(b) At least every three years, conducts an onsite survey of each entity that performs credentialing functions on behalf of the organization or if not conducting the survey onsite, then randomly requested credentialing files are sent to the organization within 24 hours of the request. [4]

As the interpretive information explains, the purpose of this change is "to indicate that in lieu of an onsite survey for conducting oversight of delegated entities for credentialing, the organization may randomly select credentialing files to be sent to it within 24 hours of the request."  

The word "survey", used here and in Core 17 , also dealing with delegation, has always been a bit confusing to some URAC applicants.  This language addresses that confusion head-on, at least for delegation of credentialing.  The term remains undefined for other forms of delegation, however, and I wouldn't be surprised to see the Core delegation standards amended in some future version along the lines of this revision.

The existing standard in both the Health Plan and Health Network standards reads:

The organization provides written notification to providers of the
determination of the providers’ credentialing application within 60
calendar days of the determination. (Secondary) [Wt = 3]

The new standard reads:

The organization provides written notification to providers of the
determination of the providers’ credentialing application within 10
business days of the determination. [4]

This revision carries two important changes. The substantive change is to reduce the notification requirement deadline from 60 calendar days to 10 business days, slicing about 6 weeks off the process. While most of our clients will meet the new timeline, some applicants will have to tighten up their processes.

The second change is an increase in the weight from 3 to 4. Because this is a single-element standard, however, we believe that it will carry less relative weight in the new system than it does now.

This standard provides:

The organization establishes provider selection criteria that address: (Primary)
    (a) Quality of care; (Primary)
    (b) Quality of service; and (Primary)
    (c) The business needs of the organization. (Secondary)

Subsections (a) and (b) are relatively straightforward.  For (a), most URAC applicants submit their credentialing requirements, such as valid, unrestricted license in the applicable state, current DEA certificate (if applicable), appropriate education and training for specialty, board certification in specialty, proof of liability insurance or self insurance, good standing with Medicaid and Medicare, etc.  For (b), we usually see requirements regarding responsiveness of the provider’s office staff, cleanliness of the provider’s office, hours of operation, and the like.  

Subsection (c) is a bit trickier for some.  As URAC's interpretive comments note:

NM 3(c) is intended to allow the organization flexibility in not accepting providers that otherwise meet the criteria for quality and service.  For example, if the organization already has enough qualified primary care providers, it might not accept another qualified primary care provider based on business needs.

Make sure your documentation gives you the flexibility to say "no" if your network is full in that specialty or some other business reason has you want to restrict a network (except, of course, if you operate in a state with an "Any Willing Provider" law).  

This standard addresses the qualifications of the senior clinical staff member.  URAC proposes no substantive changes to the standard, nor does it propose a meaningful change in scoring (beyond the overall scoring system change discussed elsewhere).  The only changes are a subtle attempt to clarify in the interpretive information associated with the standard. 

The new standard would read:

The organization designates at least one senior clinical staff
person who has: (---)
(a) Current, unrestricted clinical license(s) (or if the license is
restricted, the organization has a process to ensure job
functions do not violate the restrictions imposed by the state
licensure board); (Wt = M)
(b) Qualifications to perform clinical oversight of the services
provided; and (Wt = M)
(c) Post-graduate experience in direct patient care; and (Wt = M)
(d) Board certification (if the senior clinical staff person is an M.D.
or D.O.). (Wt = 3)

The interpretive changes are twofold:  First, an addition to the interpretive information makes it clear that it is the senior clinical staff person's responsibility to assure staff access to qualified clinical people.  Second, by creating a definition for the word "oversight" ("Monitoring and evaluation of the integrity of program processes and decisions affecting consumers"),  URAC intends to clarify the duties of this particularly important person.

I invite your comments as to how this will change anybody's approach to the URAC accreditation process.  URAC seldom does anything without a reason (or at least a history), but that doesn't necessarily mean that it will change your life.  Please let me know if it will.

The proposed new Core 6 would read:

The organization implements a policy to: (---)
(a) Verify the current licensure and credentials of licensed or certified personnel/consultants upon hire, and thereafter no less than every 3 years; (Wt = M)
(b) Require staff to notify organization in a timely manner of an adverse change in licensure or certification status; and (Wt = M)
(c) Implement corrective action in response to adverse changes in licensure or certification status. (Wt = M)

There is no proposed change in the content of the standard, so scoring is the only change.  Realistically, this is exactly the kind of standard that is unaffected by the new scoring system.  The reason is that the current version is already mandatory, and each of the three elements is a "primary" element.  So, under both the current and proposed versions of this standard, if you miss one element, you've blown your shot at full accreditation.  

So, no change here. 

CR 3, describing the structure and responsibilities of the Credentialing Committee, reads:

The organization establishes a credentialing committee that: (Primary)
    (a) Includes at least one participating provider who is a practitioner and who has no other role in organization management; (Primary)
    (b) Discusses whether providers are meeting reasonable standards of care; (Primary)
    (c) Accesses appropriate clinical peer input when discussing standards of care for a particular type of provider; (Secondary)
    (d) Has final authority to: (Primary)
        (i) Approve or disapprove applications by providers for organization participation status; or (Primary)
        (ii) Delegate such authority to the senior clinical staff person for approving clean applications, provided that such designation is documented and provides reasonable guidelines; (Primary)
    (e) Maintains minutes of all committee meetings and documents all actions; (Secondary)
    (f) Provides guidance to organization staff on the overall direction of the credentialing program; (Secondary)
    (g) Evaluates and reports to organization management on the effectiveness of the credentialing program; (Secondary)
    (h) Reviews and approves credentialing policies and procedures; and (Secondary)
    (i) Meets as often as necessary to fulfill its responsibilities, but no less than quarterly. (Secondary)

The standard carries a weight of "4", and has a number of primary elements, so it's fairly easy to lose a significant number of points if your documentation is not up to par.  For purposes of the application at the AccreditNet submission stage, URAC recommends a detailed organization chart of the entire credentialing program, including the committee, as well as formal credentialing plan and P&Ps.  In addition, meeting minutes from the Credentialing Committee are essential to demonstrate that the plan and P&Ps are being implemented.

In recent reviews, URAC reviewers have been known to "ding" an application that doesn't provide enough detail about the participating providers on the committee.  URAC has said that it wants, specifically, "a description of the participating provider(s) member(s) and the requirements, terms, duration, selection procedures of their committee responsibilities."

Another recently noted stumbling block has been around subsection (d)(ii).  Even where your P&Ps note that the committee has the authority to delegation the handling of "clean claims" to the medical director, if your documentation does not actually indicate that it has (or has not) so delegated, you're likely to get the following comment back from the reviewer:

"Clarify whether or not the committee delegates approval of clean applications to the senior medical director."

URAC is likely to accept a variety of types of documentation to demonstrate this, either in the form of a P&P, committee charter, or committee minutes showing the act of delegation.

 In revising the Independent Review Organization standards from v. 3.0 to v. 3.1, URAC has modified the stem of IR 4, the mandatory standard dealing with reviewer credentialing.  In version 3.0, the stem read:

The organization establishes and implements selection criteria for reviewers, and implements a program to verify, and re-verify at least every three years, the qualifications of all reviewers.

Version 3.1 modify that stem to read as follows:

The organization establishes and implements selection criteria for reviewers, and implements a program to verify current unrestricted credentials (prior to assignment of any reviews), and re-verify at least every three years, the qualifications of all reviewers.

Obviously, the big change here is the requirement that the organization make sure that it has verified that a reviewer has current unrestricted credentials before it assigns that review or any reviews at all.  The best explanation for such a revision is that some applicants for accreditation had a program for verification that was not sufficiently rigorous, and, in fact, forwarded reviews to reviewers who had not gone through the credentials verification process.  This mandatory standard is now unambiguous in its prohibition of such a practice.

The revised version of the standard, in full, now reads:

The organization establishes and implements selection criteria for reviewers, and implements a program to verify current unrestricted credentials (prior to assignment of any reviews), and re-verify at least every three years, the qualifications of all reviewers.   At a minimum, such a program shall address: (Primary)

(a) Verification of professional credentials, including (Primary)

(i) Current licensure; (Primary)

(ii) Current board certification, if applicable; (Primary)

(iii) History of sanctions and/or disciplinary actions; and (Primary)

(iv) Professional experience; (Primary)

(b) Potential conflicts of interest. (Primary)

As a URAC news release of a few weeks ago indicated, there is a new certification program available for international vendors of credentialing services.  Aparently, URAC has detected a need for some URAC-accredited companies to have certification of its international vendors who take on some of the labor-intensive aspects of the provider credentialing process. 

To gain certification, an international credentialing vendor will go through a mini-accreditation review.  At least at first, it seems that such applicants will not face an onsite review.  Rather, in addition to a special application for this certification program, applicants will need to comply with all of the Core standards as well eight of the standards from the credentialing section of the current Health Plan standards, P-CR 5-10, 12, and 14.  

Integral Healthcare Solutions is in the midst of a conducting research into the phenomenon of international credentialing vendors.  We will release the results of our research within a few weeks.  Our early results are pretty interesting, but we'll not jump to any conclusions until we're a bit farther along in our research.  Let us know at info@integralhs.com if you would like to get a copy of our report.  Or, just subscribe to this blog (yes, it's still free!), as we'll be publishing those results here. 

Core 6 provides:

The organization implements a policy to:
(a) Verify the current licensure and credentials of licensed or certified
personnel/consultants upon hire, and thereafter no less than every 3 years;
(b) Require staff to notify organization in a timely manner of an adverse change in
licensure or certification status; and
(c) Implement corrective action in response to adverse changes in licensure or
certification status.

Again, the first thing to note about this standard is that it is mandatory. Furthermore, every subsection of the standard is a "primary element", which means that there is no aspect of the standard that an organization can miss and still expect to gain full accreditation.

The documentation required for the standard in the application is straightforward: job descriptions and a policy and procedure that addresses all three elements of the standard. The documentation for the on-site review, on the other hand, is usually where the problems arise, if there are any. During the on-site review, the URAC reviewer will request a listing of all the members of the staff (at least those that are the subject of the review), randomly select several of the staff members, and ask to see their personnel files. The reviewer will be checking the job description and resume of each of the selected employees to see if the employees meet the requirements of the job as described in the job description. In addition, the reviewer will be looking for evidence that the employee's required licenses and certifications have been verified. Therefore, a best practice is for the organization to conduct periodic audits of all of its clinical staff members' personnel files to make sure that this is happening on ongoing basis, and particularly before the reviewer arrives.

It is important to note that the scope of the standard is broad: "licensed or certified personnel/consultants". While these are not defined terms, it is fairly clear that the URAC standard would sweep up a pretty broad array of licensed and certified people, not just employees.

One thing to note is that the standard applies not only to licensure, but also to certification. This is particularly important with respect to accreditation standards such as case management, where certification might be a requirement. Be sure, therefore, that your process of verification, both as described in your policy and procedure and in practice, includes all certifications that might be required by the particular accreditation standards under which you are applying or by your own policies and procedures.

Finally, make sure not only that your policy and procedure on the subject imposes an affirmative obligation on the licensed personnel and consultants to notify the organization of adverse changes in licensure or certification status, but that everybody has been trained on this obligation. It would not be a good thing in an interview with a member of your staff if it became apparent that this requirement was unknown to licensed or certified staff members.

"We don't delegate credentialing, so I guess that means we don't have to worry about CR 17."

Wrong.

This standard provides:

The organization complies with the Core Standards for any credentialing functions it delegates to another entity. In addition, the organization: (Secondary)

(a) Retains authority to make the final credentialing determination regarding any provider; and (Primary)

(b) At least every three years, conducts surveys of each entity that performs credentialing functions on behalf of the organization. (Secondary)

If, in your Application submission to URAC, you merely state the present reality that your organization does not currently delegate credentialing, your submission is incomplete if you do not make it clear that the standard is wholly inapplicable.

How do you do that? One way would be to submit a policy that your organization will not delegate credentialing. However, if you forsee any possibility that, at some point in the future, you may delegate credentialing, you must submit a policy that addresses all elements of the standard.