Professional References

Professional references are required to meet health care facility licensing and accreditation standards. Participating facilities rely on MPR to obtain three professional references in completing an initial appointment application. Many participating facilities require one professional reference at the time of reappointment to meet specific accreditation standards.
Professional references are a key component to the credentialing effort as they offer the opportunity to attest to the current clinical competency (see previous blog – What is a CME Listing and Why is it necessary?) on any provider making initial appointment, at the time of reappointment if new clinical privileges are requested or if a new clinical privilege form is completed. MPR also uses professional references if additional privileges are requested by the provider outside an initial appointment or reappointment process.

The Joint Commission standards require a professional reference to address 6 separate competencies:

  1. Medical/Clinical Knowledge
  2. Technical and Clinical Skills
  3. Clinical Judgment
  4. Interpersonal Skills
  5. Communications Skills
  6. Professionalism

It is for this reason MPR is not able to accept a general letter of recommendation from a professional colleague of the applicant/provider.
The MPR initial appointment application requests five professional references and the reappointment application requests two (2) professional references. Requesting additional reference names allows the MPR team to: 1) reduce our turn-around-time by taking the first three references returned at the time of initial appointment and 2) use additional references listed when references don’t respond to our request or feel they are unable to attest to the clinical competency of the provider.
If you were to ask any CVO in the nation what is the most common obstacle of completing a credentialing file, the answer will most likely be obtaining professional references. MPR greatly appreciates the dedicated efforts of the office/practice managers and credentialing contacts as they are often able to assist in notifying the professional references listed on the application prior to the request being made. These contacts reduce the turn-around-time of providing a completed credentialing file to the health care facility and thus expedites the process of allowing the provider to begin practice. That is a win for MPR and a win for the provider!

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What is a CME Listing and Why is it Necessary?

CME (another acronym in our credentialing world) stands for Continuing Medical Education and is used to qualify/determine current clinical competency of the provider.  Different providers require different levels of CME activity. For new physician graduates we typically get this information from residency procedure logs and we use procedure activity logs for other provider types.  The MPR team is instrumental in collecting this information both at the time of initial appointment and every two years at reappointment (unless other requirements apply per the participating health care facility) when clinical privileges are requested or renewed.

One consistent question is how the information is best collected.  Most would agree, it is best collected in a line listing indicating the sponsor of the event, topic of the course, date and number of hours assigned to the specific activity.  The alternative is a collection of a variety of different CME certificates. This is not optimal as it adds bulk to the credential file and is more difficult to discern clinical competency.

MPR health care facility clients are licensed or accredited by a variety of different agencies/organizations including CMS, HFAP, Joint Commission, AAAHC, etc. (a definition of each can be found on our Glossary of Terms on the MPR website).  Each standard reads a little differently on the CME requirements.  The current Joint Commission standard reads:

“All licensed independent practitioners and other practitioners privileged through the medical staff process participate in continuing education.  Continuing education is an adjunct to maintaining clinical skills and current competence.  Each individual’s participation in continuing education is documented.  Participation in continuing education is considered in decisions about reappointment to membership on the medical staff or renewal or revision of individual clinical privileges.” – MS12.01.01

MPR, with the help of the provider, will produce the credentialing file to meet the standards of each participating health care facility.  We look forward to working with the provider and office personnel in obtaining CME information and presenting the information to the participating health care facilities in assisting them in meeting all credentialing standards.

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Continuous Query Through the National Pratitioner Data Bank

The National Practitioner Data Bank was introduced in response to the National Health Care Quality Improvement Act of 1986.  It was first designed as a central clearinghouse of information mandated to be accessed when granting privileges and every two years upon reappointment.  It remains a central clearinghouse today and is now offering pertinent information on providers (physician and allied health practitioners) relative to credentialing decisions.

Enrollment in the continuous query first became available to authorized users a few years ago and provides automatic notification of anything reported to the databank on behalf of any provider currently enrolled.  Unlike the traditional query of the data bank upon initial appointment, reappointment and when privileges are granted, the continuous query is an annual enrollment of providers.  When providers leave the health care facility, it is necessary to deactivate the provider’s enrollment in the continuous query.

In response to current best practice, MPR enrolls all providers into the continuous query and maintains the enrollment as necessary.  The reports received by the participating health care facility are forwarded to the facility as we are notified.  Although it is possible to set the parameters of notification to allow the facility as well as MPR to be notified simultaneously, MPR will continue to forward reports as we receive them since we do not control how the original parameters are designed by each facility.

If you would like to see the list of mandated reportable incidents, please see the NPDB Guidebook at

I feel the continuous query provides valid data for all medical staff professionals (MSPs), but shouldn’t be deferred to as the only opportunity to gather data on providers as there are limitations on what data is available.  Like all verifications, it does have its limitations and we should defer to several different primary source verifications to create a balanced approach to gathering data to substantiate current clinical competence.

I welcome your questions and input on the continuous query option and look forward to our next posting in the educational blog series.

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Verification of Hospital Affiliations

Have you ever walked through the grocery store and spied that piece of chocolate you have been craving?  Then comes the internal conversation…”do I want this piece of chocolate or do I need this piece of chocolate? After all chocolate has some documented benefits (especially if it’s dark chocolate), but it also comes with some calories that maybe I don’t need or require. And although it may come with some dietary benefits in small portions, I’m not sure I can put chocolate in the health food category.”  Darn.  I wish chocolate was necessary to our human existence.  Wouldn’t that be a great world?

Hospital affiliation verifications seem to be in the same category as chocolate.  You may want them but do we need them?  And if we do need them how many do we need or require? Let’s explore that question.

I believe this approach to hospital affiliation verifications can be summarized in two categories:  1) the culture of the health care facility and 2) the depth of verification needed to establish current clinical competency.

Let’s address the culture first.

1)    Verification of all hospital affiliations has been a traditional component of credentialing for many years.  It has only been in the past 5-10 years that health care facilities have considered verifying some –but not all- affiliations.

2)    Health care facilities originally verified hospital affiliations to identify any gaps in practice.

3)    Many health care facilities believe verification of hospital affiliation is required by regulatory/accreditation agencies.  That simply is not the case.  In March, 2010, The Joint Commission (TJC) posted the following answer to the question of hospital affiliations:

Q. Are organizations required to verify affiliations at other health care organizations, and if yes, for how many years back must the verifications be done?

A. There are no standards requirement to verify hospital/other healthcare organization affiliations or privileges/clinical responsibilities or work history for any applicant. The hospital MS.06.01.05 and MS.06.01.13 and the HR.02.01.03 requirements are to evaluate:

  • voluntary or involuntary relinquishment of any license or registration
  • voluntary or involuntary termination of medical staff membership
  • voluntary or involuntary limitation, reduction, or loss of clinical privileges

Now let’s move to depth of verification.

1)    Practitioners have many more hospital affiliations than in previous years because of managed care plans. In many cases, practitioners have affiliations they never or rarely use.  This is why we are increasingly addressing the need for “low volume practitioners.”

2)    Applications promoted and/or mandated by states increasingly ask for only more recent history related to an applicant’s current/previous hospital affiliations.

3)    Health care facilities are now credentialing practitioners who may have hundreds of current/previous affiliations because they are involved in telemedicine or provide locum tenens services.

My take a-ways:

1)    Because the missions of credentialing is to document current clinical competency, health care facilities should carefully consider the value of verifying some – or all- current/previous hospital affiliations.  What depth of verification is required to document current clinical competency?

2)    Current clinical competency is also documented by professional peer references and so maybe we should consider how many professional peer references should be required (current industry standard is 3).

3)    MPR will continue to meet the need of each client individually in recognizing the culture of each facility and the depth of verification defined to document current clinical competency.

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Required Documents (Part 2) Why are they important?

Specialty Board Certificate(s) – Several MPR participating health care facilities require board certification or eligibility to be considered for staff membership/clinical privileges.  These documents provide the basic information needed to primary source verify a provider’s specialty board certification.

Line Listing of Current Continuing Medical Education (CME) Courses – The CME listing is not required by credentialing surveyors, but is preferred to copies of the certificates of attendance at various CE activities.  The surveyors will open the credentials file and place the line listing of CMEs with the privileges requested and approved for the provider.  The CME listing is used to verify a provider is attending courses that are directly related to the privileges requested.  Although CMEs are requested from providers at the time of licensure and re-licensure, they are necessary for the credentialing process to document current clinical competency to the privileges requested at the time of initial appointment and reappointment to the staff.

Military Discharge Papers – The DD 214 has become the standard document for proof of military experience.  Although the DD 214 is requested at the time of initial appointment, it is also the responsibility of MPR to primary source verify military experience with the National Personnel Records Center.  Both the DD 214 provided by the applicant and the primary source verification of the document are provided to the participating health care facilities in the completed credential file.

Current Alien Registration Card/VISA – The credentialing process requires documentation of the current VISA status.  A copy of the card is requested at the time of initial appointment and included in the completed credentialing file to the participating health care facility.

Residency Log of Procedures – It is the responsibility of MPR to document current clinical competency.  A listing of procedures performed during residency of graduates making application for initial appointment within one year of graduation from a residency program provides the necessary documentation for current clinical competency in the procedures requested.  The participating health care facility will determine if the number of procedures listed meets the facility-specific requirements to meet the definition of current clinical competency in the privileges requested.

Government Issued Photo ID – The credentialing standards require MPR to verify a provider’s ID through a government-issued photo ID (driver’s license, passport or military ID).  To meet this standard, we ask questions on both the hospital affiliation requests and professional references that allow the respondent to verify the person they are completing the verification on is the same person depicted in the photo attached to the request.  We are often asked if information can be redacted from the photo ID.  In addition to the photo of the applicant, there are three required data elements on the photo ID:  1) name of government agency (i.e, Kansas Department of Revenue), name of provider and date of birth.  All other information can be redacted from any government-issued photo ID.

Note:  Other photos are also requested from the provider (1 for each participating health care facility for which the applicant is applying) to include in facility or organization directories.

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Required Documents (Part 1) Why are they important?

If you complete an MPR initial appointment application you will find a list of required documents.   I am often asked, “Why do you request these documents?”. I think this question is worth exploring.

Current Curriculum Vitae: Commonly referred to as the CV, this document is considered additional/supplemental information to the application by most credentialing standards.  Because it is considered additional information, it is necessary that MPR verify the items on the CV as well as those listed on the application.  It is preferable the CV match the information on the application because the applicant doesn’t want to appear to be submitting false or fraudulent information on one document or the other.  At MPR we struggle with CVs that are different from the application as it is our responsibility to primary source verify all information.

Current DEA Registration: The DEA is a key document in considering an applicant for privileges.  Although it doesn’t apply to all providers (radiologist and pathologist often times do not prescribe medications and do not require a DEA)  it is the responsibility of the health care facility to verify the provider has a current DEA before they begin to practice at the facility.  Please see my blog on DEA requirements.

Current Certificate of Insurance to Include Proof of Participation in the Kansas Health Care Stabilization Fund: Each participating health care facility requires proof of malpractice insurance prior to granting membership/privileges.  MPR is required by contract with each participating health care facility to produce a current certificate of insurance in the completed credentialing file.  Participation in the Kansas Health Care Stabilization Fund is mandated for most credentialed professionals by the state of Kansas.  Please see my previous blog on the Kansas Health Care Stabilization Fund.

Current Life Support Certificate (ACLS, BLS, PALS, etc.): These certificates are required by some participating health care facilities for providers working in the emergency department.  MPR will track these documents and keep them current for each provider working at a facility requesting our services in tracking these documents.

Post-graduate/medical/osteopathic/dental degree(s) and Certificate of Training (PGY1, Residency, Fellowships, etc.): These documents are often requested by the originating school when verification requests are submitted.  A copy of the training certificate provides the primary source with the proper information from which to locate the record for verification.  MPR will enclose a copy of the certificate with the verification request.

ECFMG Certificate: This certificate is issued by the Education Committee for Foreign Medical Graduates.  Verification of the ECFMG is preferred by MPR to primary source verify education from any professional school not on US soil.

Next week, Required Documents (Part 2) will be posted!

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Different Credentialing Models for Different Cultures

Sometimes it is hard to admit how long you’ve been doing credentialing.  For me personally, it dates back 20+ years.  Through the years, I’ve seen several credentialing models.  Some have been effective and others have failed.  Credentialing models are primarily created as new information is introduced and made available, for example, the development of the Practitioner Data Bank brought new credentialing models to the surface as the industry explored the impact of information available.  But other models are adopted to survive the reality of doing more with less.  For instance, hospital affiliation letters have changed over the years.  The older credentialing models relied heavily on hospital affiliation letters because they simply reflected how the provider was performing at each hospital.  I remember copying and attaching clinical privilege forms we were using and actually receiving a copy of the clinical privileges the provider held at the hospital providing the verification.  Those days have obviously disappeared as hospitals are required to perform more with restricted hours.  The majority of current hospital affiliations reflect either a referral to the Practitioner Data Bank or provide minimal information of appointment dates and staff category.  The Joint Commission does not require hospital affiliation letters any longer although they can be instrumental in identifying gaps in practice history.

Some hospitals have adopted to accept the AMA physician profile as primary source verification and build information not included on the profile into the credentialing file.  Other profiles include the Federation of State Medical Boards and the AOA Profile for osteopathic physicians.  Regardless of the credentialing model adopted, traditional verification letters are required.   These letters can include (but are never limited to) education, training, work history, hospital affiliation, claims history, professional references, etc.  The list could actually be endless in acquired data verification.  Whatever model is adopted for credentialing, it is important the model reflect the current culture of the facility.  In other words, what is important to the facility or what is important to the credentials committee, the medical executive committee or the governing board.  The key questions to ask in developing a credentialing model include how much information do I want to collect?  Is the information meaningful or meaningless?  How long will it take to verify the data elements required?

Not only do the verification letters need to reflect the current culture of the facility, but the content of the verification letters needs to request specific information needed to meet cultural needs.   Best practices in the credentialing industry reflect professional reference letters that attest to knowledge on 6 different clinical competencies (more to come in a future blog).   In addition, whatever credentialing model is adopted, it should be systematic and routinely applied to all credential files.  The facility should develop credentialing policies and procedures that reflect the facility culture.

The role of MPR is to adopt a credentialing model that is flexible to meet the needs of all our clients and meet specific facility cultural needs/requirements in a timely manner.  This is the goal of MPR and we are committed to meeting the need.

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The Three C’s of Credentialing

I am often asked the question…what is credentialing?  I always have a one-word answer.  Verification.  But what do we verify and why?  That’s a better question.  Why do we credential providers?  Now, that will take a blog entry to explain and begins with three words…current clinical competency.  We call these the 3 C’s of credentialing.  And these three C’s are universal to any credentialing model and apply to all licensing and accreditation requirements.

At MPR we have clients across the mid-west with varying licensing and accreditation standards.  Some clients are accredited by The Joint Commission (TJC), while other clients are accredited by the Health Facilities Accreditation Program (HFAP).  There are others such as Det Norske Veritas (DNV) and our ambulatory surgery centers are accredited by the Accreditation Association for Ambulatory Health Care (AAAHC).  Most of our critical access hospitals (CAH) are licensed by the Centers for Medicare & Medicaid Services (CMS).  The common denominator in all these licensing and accreditation requirements is current clinical competency.

At MPR we verify current clinical competence in two different methods:  1) through primary source verification of education and training and 2) through professional peer references. Each verification requires the responding provider/entity to attest to the current clinical competency of the provider in verification of observing, instructing or training. The Joint Commission requires primary source verification of professional and clinical performance that must include peer references and suggest using 6 general competencies for evaluation.  MPR has adopted these 6 general competencies and request them on all our professional peer reference letters.  Another method of providing documentation to prove current clinical competency is the case logs/activity logs of the provider.  These are required for the initial appointment process and the reappointment process as proof of on-going clinical competence.

In the past, hospital affiliation requests were used to verify current clinical competency, but what we are finding is the verification responses have been deduced to form letters stating staff category and beginning and ending dates of appointment.  This is true industry-wide and a true testament to the tremendous workload the medical staff services departments have around the country.

While MPR doesn’t decide what privileges a provider receives at the facility, we are instrumental in providing documentation to assist the facility in making quality decisions about granting clinical privileges. In this series of education blogs I will addressing and defining different elements of the MPR file as we fully address what we do and why we do it.

As always, I welcome your questions and feedback.  So please feel free to join the discussion.

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MPR is Launching an Educational Blog Series!

Education and communication are the keys to success. I’m convinced this is a true statement and it has become a mantra in the MPR office. We often receive questions….Why do we ask for the things we ask for?  What do we do with the information we receive? I want to be responsive to the questions we receive.

MPR recently celebrated our one-year anniversary. This week I am excited to launch a series of educational blogs addressing a different topic each week.  Many of these blogs will cover topics I’ve been asked repeatedly and some blogs will cover new territory in addressing items such as the ECFMG – what is it and why is it necessary?

It’s important that we have the same information to work from and the ability to reference the information necessary when questions do come up.  My hope is the blogs will provide both education and communication as we move forward.  I have a list of topics to present but if you have questions you would like addressed, please let me know (

I look forward to taking this educational journey with each of you.

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What’s New on the Horizon – Hot Topics

I have three children that play tennis.  Everyone who plays the game knows success is based on focusing on where the ball is going to be and not where it is at the moment.  I recently attended the National Association of Medical Staff Services (NAMSS) conference in San Francisco.  Several new ideas and approaches to credentialing were introduced and I thought it was worth taking a moment to share a brief summary of many hot topics with you as we “keep our eye on the ball”.

Let’s begin with the APP vs. the AHP

The world of credentialing is full of acronyms. An acronym that has been around for some time now but is just now making its way to the majority of us in Kansas is the APP or Advanced Practice Practitioner. This is a subcategory of Allied Health Practitioners or AHPs as we’ve come to know them. APPs are those AHPs that have advanced degrees giving them the opportunity to play a key role in the clinical course of treatment for the patient. Many hospitals are struggling with how to assess the clinical competency on the AHP/APP. The best practice is to request an activity log at the time of initial appointment and reappointment so the hospital can measure that against the clinical privileges being requested. The future credentialing model will treat APPs just as the medical staff members with all the required documentation.


NAMSS recognizes The Joint Commission (TJC) does not require a timeline-credentialing model where all hospital affiliations and work history affiliations are verified. NAMSS does, however, support affiliation verifications and is launching a new service called NAMSS PASS. This service will require voluntary participation of hospitals and physician employers around the country. The end result will be a centralized collection of all physician affiliation documentation (hospitals, work history, academic affiliations). Those entities requiring the information will be charged a fee for access to the NAMSS PASS. This is a great idea in theory but will rely on voluntary participation of hospitals and physician employers around the country. Unlike the verifications we request now where most are free, this verification will come at a price. The Joint Commission is most likely to accept the NAMSS PASS as primary source documentation, although this has yet to be determined. More to come on the NAMSS PASS….

New Credentialing Models

The world of medicine as we know it is ever changing and different credentialing models are necessary to meet the demand. Accountable Care Organizations (ACO) and medical home groups and other physician alignment models are being developed in the country and each will require some type of credentialing response. That response has yet to be determined because the new models will embrace some type of economic credentialing approach (who’s in and who’s out).  Economic credentialing has not been popular in the past but will soon become the necessary standard of credentialing in some health care alignments.


Many of us have heard of the Maintenance of Certification (MOC) required by some boards of the American Board of Medical Specialties (ABMS). The MOC has not been fully adopted by all ABMS boards but it does seem to be the path of the future. Maintenance of Licensure (MOL) is a model being developed by the Federation of State Medical Boards (FSMB). This model is similar to the Maintenance of Certification (MOC) and Osteopathic Continuous Certification (OCC) in that it requires a provider to provide proof of continuous competency via classes attended (traditional CME requirements), participation in clinical activities (an expanding area of competency) and other forms of documentation. Although the MOL has not been implemented yet, this strategy of licensure requirements is being fully and aggressively embraced by the FSMBs.  If implemented by all state licensure boards, the Kansas State Board of Healing Arts (KSBHA) will be developing the requirements for Kansas. My questions include the following: Will this eliminate the annual licensure renewal as all licensure is continually maintained? When will MOC be required for all boards? So far the American Board of Pediatrics has adopted it in 2010 but no other boards. Several boards are moving toward the MOC model. In any event this is where we are headed in the future.

I hope this summary of what is on the horizon provides an indication of where credentialing paths may lead in the future as we keep our eye on the ball of credentialing. I, like you, have many questions, but I’m confident we can approach these models together as we respond to the documentation needed.



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