Credentialing, Recredentialing, and Privileging: The
Basics and Beyond
Kathy Matzka, CPMSM, CPCS
1304 Scott Troy Road
Lebanon, IL 62254
Phone (618) 624-8124
BIOGRAPHICAL SKETCH, KATHY MATZKA, CPMSM, CPCS
Kathy Matzka, CPMSM, CPCS is a speaker, consultant, and writer with over 25 years of experience in credentialing, privileging, and medical staff services. She holds certification by the National Association Medical Staff Services (NAMSS) in both Medical Staff Management and Provider Credentialing. Ms. Matzka worked for 13 years as a hospital medical staff coordinator before venturing out on her own as a consultant, writer, and speaker.
Ms. Matzka has authored a number of books related to medical staff services including Medical Staff Standards Crosswalk: A Quick Reference Guide to The Joint Commission, CMS, HFAP, and DVN Standards, Chapter Leader’s Guide to Medical Staff: Practical Insight on Joint Commission Standards, Compliance Guide to Joint Commission Medical Staff Standards, and The Medical Staff Meeting Companion Tools and Techniques for Effective Presentations. For eight years, she was the contributing editor for The Credentials Verification Desk Reference and its companion website The Credentialing and Privileging Desktop Reference. She is co-author of the HcPro’s publication Verify and Comply: Credentialing and Medical Staff Standards Crosswalk, Sixth Edition.
She has performed extensive work with NAMSS’ Library Team developing and editing educational materials related to the field including CPCS and CPMSM Certification Exam Preparatory Courses, CPMSM and CPCS Professional Development Workshops, and NAMSS Core Curriculum. These programs are essential educational tools for both new and seasoned medical services professionals. She also serves as instructor for NAMSS.
Ms. Matzka shares her expertise by serving on the editorial advisory boards for two publications - Briefings on Credentialing, and Credentialing & Peer Review Legal Insider.
Ms. Matzka is a highly-regarded industry speaker, and in this role has developed and presented hundreds of programs for professional associations, hospitals, and hospital associations on a wide range of topics including provider credentialing and privileging, medical staff meeting management, peer review, negligent credentialing, provider competency, and accreditation standards.
In her spare time, Ms. Matzka takes pleasure in spending time with her family, listening to music, traveling, hiking, fishing, and other outdoor activities.
Table of Contents
Application Process 4
Exercise: Applying Criteria for Medical Staff Appointment 6
Verification of Application Information 16
Education and Training 16
Sample Letter for Verification of Training 18
Peer Recommendations 22
Work History and Affiliations 26
Sample Letter: Facility Privileges and Competency Validation 27
Sample Policies and Procedures for Credentialing 30
Verification of Current Licensure and Licensure Sanctions 31
Notification of Internal and External Parties Regarding Practitioner Privileges 33
NPDB Query 35
Identification of Excluded Providers 36
Criminal Background Checks 37
Using The AMA Physician and AAPA Physician Assistant Masterfile Query 39
Liability History/Proof of Insurance 40
Health Status/Ability to Perform 41
Board Certification 41
Verification Of Identity 43
Sample Policy and Procedure for Verification of Identity 44
Privileges Resources 45
“Laundry List” Example 46
AAFP Core Privileges Example 48
HCPro Core Privileges Example 53
Modified Core Example Family Medicine 63
Work Sheet For Consideration of New Privilege 68
Structured Interview Questions 69
Documenting Recommendations 70
Minutes Language 70
Recommendation and Approval Form for Medical Staff Appointment and Clinical Privileges 72
Understanding Negligence in Credentialing 74
CREDENTIALING, RECREDENTIALING AND PRIVILEING BASICS
Some organizations use a preapplication form to screen applicants to determine membership eligibility. This form typically contains address, education, training, licensure, board certification, amount of professional liability insurance, distance from home or office to the healthcare facility and any other membership requirements the organization may have. For instance, if a hospital requires the provider to be board certified and he/she is not, this can be evaluated prior to the application process and the provider can be notified that he/she is not eligible for appointment. On the other hand, using a preapplication adds another step and may delay the appointment process.
Organizations have individualized forms or may use a standardized form developed by the healthcare network or State. The application form typically contains the following information:
demographics - name, professional degree, DOB, social security number, UPIN, home and office addresses, phone, fax, pager and cellular phone numbers;
education and training information - names and addresses of schools, internship, residency and fellowship programs, type of program and name of program director;
ECFMG information if applicant is a foreign medical graduate;
current and past licensure and narcotics registrations;
board certification information including current status, name of specialty and subspecialty boards;
peer references who have personal knowledge of the quality of medicine practiced by the applicant;
current and past healthcare organization affiliations; and
military service, if applicable.
An applicant may have to answer questions regarding the following issues:
voluntary or involuntary loss of medical staff membership and voluntary or involuntary limitation reduction, or loss of clinical privileges at another healthcare organization;
previous or pending successful challenges to any licensure or narcotics registration or involuntary relinquishment of licensure or registration;
past and current professional liability insurance carriers, including policy numbers, amounts and dates of coverage;
past or pending professional liability action, including information about final judgments or settlements involving the applicant;
misdemeanor or felony convictions;
denial of participation, suspended from, denied renewal from the Medicare or Medicaid program, or participation status modified;
illegal use of drugs; and
ability to safely exercise the privileges requested with or without reasonable accommodation.
Professional Practice Questions
Before granting privileges, the medical staff should evaluate:
challenges to any licensure or registration;
voluntary and involuntary relinquishment of any license or registration;
voluntary and involuntary termination of medical staff membership;
voluntary and involuntary limitation, reduction, or loss of clinical privileges; and
any evidence of an unusual pattern or an excessive number of professional liability actions resulting in a final judgment against the applicant.
Attachments to Application
In addition to the application itself, organization may require attachments to be included. These attachments are considered a part of the application and the application is not considered complete until they are submitted.
Sample attachments may include:
application fee; and
clinical privileges request.
Review for Completeness
The application should contain a chronological history starting with graduate education, and continuing through the date of the application. There should be not be any unaccounted for gaps.
The application is not considered complete until all required information has been provided. All questions must be answered, the information provided must be legible, all required attachments are present, and the application is signed and dated. If any information is incomplete or missing, the application should be returned to the applicant for completion.