QUESTION: We are a six-hospital system and are doing our best to address and anticipate the health care needs of patients with COVID-19. Two of our hospitals are Critical Access Hospitals, which is why our medical staffs are not unified. Nonetheless, we have a system CVO and our bylaws, credentials policy and privileging criteria are consistent. If we want to be flexible about deploying needed practitioners to our various hospitals by using temporary privileges for those practitioners who do not hold privileges at each hospital, must we get new peer references from their primary system hospital? What are our other options for granting privileges for these practitioners at hospitals in our system where they are needed?
ANSWER: Technically, each hospital with a separate CCN and license is supposed to get a peer reference to confirm current competence, under both Joint Commission and DNV GL NIAHO standards, without reference to whether a hospital is part of a system. However, under these difficult circumstances, of course it makes sense to take advantage of the system’s knowledge of privileging at other system hospitals to speed up the availability of practitioners to go where they are needed most. Here are some options:
- For those who are somewhat risk averse and have the time and resources, the system CVO (or centralized Medical Staff Office) could pre-populate a short “application” form so there would be little the “applicant” would need to do other than sign electronically. That form could refer to a standard department chief/chair peer reference communication to be used within the system, which confirms current competence based on OPPE (or FPPE if applicable for recently appointed practitioners) or the last reappointment recommendation/report. However, those under a performance improvement plan or investigation would not be eligible except on a case-by-case basis.
- Pursuant to a system information sharing policy, Board resolution, or agreement, the standard department chief/chair peer references could be accessed electronically throughout the system or the actual recent OPPE or reappointment reports could simply be made available directly without the need for the separate peer reference form.
- A system could simply let the practitioners go where they are needed, via a Board and MEC resolution, and justify it later if surveyors question it. Will surveyors really cite hospitals for having moved quickly to get known practitioners to respond to the community? We doubt it.
- A few systems have created a category on each medical staff in the bylaws for all physicians who are appointed to other hospitals’ staffs. The CVO has all the information. The physicians in that category are permitted to exercise privileges at all system hospitals where the services they provide are offered, even though they designate a primary hospital. (One reason that systems do this is to create a panel of peer reviewers to review cases at other system hospitals when there is a potential conflict, or to use those physicians as locum tenens in system hospitals to avoid contracting with locum tenens firms and thereby getting unknown physicians.)
- Another option is for each hospital to grant disaster privileges quickly and as needed, in reliance on the CVO’s files containing licensure, and verify identity when they report for duty.
Join Charlie Chulack and Barbara Blackmond for the next installment in our Grand Rounds audio conference series on April 7 on Making the Most of your Relationship with Credentials Verification Organizations (CVOs).
QUESTION: We are considering having a Credentials Verification Organization (“CVO”) perform primary source verification and other required verifications for our credentialing process. Do we need to have some sort of agreement in place? If so, what should that agreement include?
ANSWER: Regardless of whether you are using an internal CVO (i.e., one that is a part of your organization) or an external, independent CVO (i.e., one that has no corporate affiliation with your hospital), there should be an agreement in place between the CVO and the hospital.
An agreement should define the obligations of the CVO, including the services that it will provide. The agreement should also specifically identify the information that will be verified and the sources that will be used for verification purposes. If ongoing monitoring of practitioners’ credentials is a part of the services the CVO will provide, the agreement should state this and indicate the credentials that will be monitored (e.g., Medicare and Medicaid sanctions and exclusions).
Furthermore, sharing of confidential credentials information should be addressed and include provisions on how sensitive information such as National Practitioner Data Bank reports and drug or alcohol treatment information will be handled and shared. If the hospital is involved in delegated credentialing for third-party payors, there are special considerations for sub-delegation agreements, which would include agreements with an external CVO to perform verification activities.
Specifically, the agreement must require semiannual reporting of the CVO to the hospital on its conduct of the contracted-for activities, describe the process by which the hospital evaluates the CVO’s performance under the agreement, and describe the remedies available to the hospital if the CVO does not fulfill its obligations, including revocation of the delegation agreement.
QUESTION: Our hospital is registered with the National Practitioner Data Bank (“NPDB”). We would like to designate as an authorized agent for NPDB querying purposes a credentials verification organization (“CVO”) with which we have recently started working. How do we go about doing this?
ANSWER: The NPDB explicitly permits the practice of eligible entities, including hospitals, designating authorized agents, such as CVOs, to query on their behalf. However, according to the NPDB Guidebook, an authorized agent must, itself, register with the NPDB and comply with all the registration requirements. Often, CVOs act as authorized agents for a number of eligible entities. Nonetheless, the CVO must query the NPDB separately for each eligible entity they represent. Moreover, the CVO is not permitted to share results of a query for one eligible entity with another eligible entity.
After the CVO registers with the NPDB, your hospital will have to designate the CVO as its authorized agent. This is a relatively simple process that can be done electronically by accessing this web address: https://www.npdb.hrsa.gov/hcorg/howToDesignateAnAuthorizedAgent.jsp. Finally, as a part of designating the CVO as an authorized agent to query the NPDB on behalf of your hospital, you will have to create a written agreement between your hospital and the CVO. The NPDB Guidebook does not identify any required elements for this written agreement, but the NPDB website provides recommendations for what should be included in the agreement. According to the NPDB website, the agreement should confirm the following: (1) the authorized agent is authorized to conduct business in the relevant state; (2) the authorized agent’s facilities are capable of maintaining the security and confidentiality of NPDB reporting and query responses; (3) the authorized agent is prohibited from using querying responses for any purpose other than that for which the disclosure was made; and (4) the agent understands that sanctions can be taken if information is requested, used, or disclosed in violation of NPDB provisions.