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Physician Credentialing and Privileging: 10 Dos and Don’ts

Published Date: July 11, 2017

If you have even a shred of doubt in your ASC's ability to perform proper physician credentialing and privileging, your alarm bells should be ringing. Not only is physician credentialing and privileging required by the federal government (CMS), state governments and accreditation agencies, it is vital to patient safety and risk management.

"If you don't appropriately credential and privilege your physicians, you are running a big risk," says Ann Geier, MS, RN, CNOR, CASC, chief nursing officer for Surgical Information Systems. "If a physician makes a mistake that harms a patient and your ASC is sued, your governing body is subject to corporate liability and won't have a leg to stand on."

Here are 10 dos and don'ts Geier recommends ASCs follow to help ensure they perform complete, compliant physician credentialing and privileging.

  1. Don't use hospital credentialing. Many years ago, Geier says it was commonplace for an ASC to consider a hospital's physician credentialing for the ASC as well. "That is no longer acceptable," she says. "ASCs must always perform their own independent credentialing."

  2. Don't underestimate workload. There is a reason hospitals often have entire departments dedicated to credentialing. "A lot of people don't appreciate how much work credentialing entails. As a result, they can fall behind quickly," Geier says. "If this happens in an ASC, it's difficult to catch up."

  3. Don't accept incomplete applications. ASCs should work to establish an effective system for physician credentialing, starting with a comprehensive application. "The application must be filled out completely," Geier says. "If you receive an application with missing information, send it back to the provider. Don't accept an application that omits any required information."

  4. Do consider outsourcing. Once you have developed an application form, you can choose to either perform credentialing in-house or outsource it to a credentialing verification organization (CVO). In some cases, outsourcing the process may be your best option.

    "While using CVOs costs money, if you're starting a new ASC, you usually don't have time to do all the credentialing required," Geier says. "Go ahead and use a CVO. They know what they are doing and will dedicate the time to ensure credentialing is done properly."

  5. Do request multiple ways to contact references. When you are requesting references from your physicians, it is worthwhile to ask for several forms of contact information.

    "If a physician gives you a reference and the address is incorrect or phone number is no longer in use, you can't easily connect with the reference and that's going to slow the process down," Geier says. "I always like to request an email address, phone number and any other contact information they can provide. You want to make sure you get responses."

    Consider a lack of responses a potential red flag, she says. "If you have left numerous messages and not heard back from a reference, this should catch your attention. While it could be nothing of concern, you will want to dig deeper to determine whether that's the case."

  6. Do use primary source verification. Go to primary sources when you need to verify credentials, Geier says. You can directly query the physician's medical school, university and/or residency program. You can also use the National Practitioner Data Bank (NPDB) or American Medical Association's (AMA) Physician Profile service.

    "If you use the NPDB or AMA, be aware that there's a small charge," she says. "You may want to consider the 'continuous query' option. You pay a fee, and any time information changes on the provider's application, you will be notified. This will make it easier to keep records up to date and is an acceptable way of meeting requirements."

    If your ASC is accredited, review your accreditor's standards on credentialing closely as you may be required to use NPDB.

  7. Don't ignore lawsuits or settlements. If physicians indicate in their application that they have pending lawsuits or previous settlements, you should research these further.

    "If physicians do not provide sufficient details on these cases, you will want to do your homework," Geier says. "You can have your medical director speak to these physicians to learn more. You can also query their medical liability provider and see what they report. Just don't accept the acknowledgement of lawsuits or settlements as sufficient."

  8. Do perform peer review. Recredentialing of physicians requires peer review.

    "Don't forget that all credentialed providers must have documented peer review," Geier says. "This includes allied health professionals, including certified registered nurse anesthetists and physician assistants."

  9. Do verify licenses. A simple task, but one that can be easily overlooked, is license verification. "Make sure someone verifies that a physician's license is current," Geier says. "Many ASCs can use their computer software system to remind them to update the information. There's no excuse for not doing it."

  10. Don't take privileging lightly. While physician satisfaction is critical to an ASC's success, the desire to keep physicians happy — and continuing to bring their cases to the center — should not override making smart clinical and financial decisions.

    "One of the most important considerations for privileging is whether your ASC is equipped and staffed to perform the particular procedures for which physicians are requesting privileges," Geier says. "Sometimes physicians will request a procedure that may not be appropriate to an ASC setting (e.g., liver biopsy). Maybe you lack the necessary equipment, so you will want to think twice before approving that privilege because it's going to involve a lot of costs to add the procedure. Or maybe a physician just learned about a new procedure at a meeting and wants to perform it at your ASC, but you do not want to allow it until you know it's safe. For these instances, consider setting up some precepting guidelines."

    ASCs should not forget that providers need to request individual privileges for each laser they will use, the use of fluoroscopy and interpretation of fluoroscopy, supervision of anesthesia providers and administration of local anesthesia, she says. "If there is special equipment required for cases, I also recommend asking for those privileges."