Medical Provider Resources was recently named a finalist for the 15th annual Small Business Awards program through the Wichita Regional Chamber of Commerce. MPR was one of three Tier 2 companies (6 to 20 full time employees), other Tier 2 finalists include Headshots Bar & Grill and National Screening Bureau. Click here to see the other finalists.
Medical Provider Resources recognizes the need to meet federal and state regulations as they pertain to basic credentialing and monitoring functions. The Social Security Death Master File is a computer database file made available by the United States Social Security Administration since 1980. The file contains information about persons who had Social Security numbers and whose deaths were reported to the Social Security administration from 1962 to the present, or persons who died before 1962, but whose Social Security accounts were still active in 1962. MPR is registered with the Limited Access Death Master File (LASMF) as an entity with a genuine fraud prevention interest.
The final rule published in the Federal Register on June 1, 2016 describes how institutions and others may become certified to received data from the LADMF. Per the CMS Medical Program Integrity Toolkit to Address Frequent Findings 42 CFR 455.436, “The Social Security Administration’s Death Master File (SSADMF) must be searched at the time of enrollment to ensure that Medicaid is not being billed in the name of a deceased provider.” Disclosure of search results outside of the MPR service agreement is strictly prohibited under 15 CFR 1110.200. Furthermore, according to the CMS Medical Program Integrity Toolkit to Address Frequent Findings for federal database checks (42 CFR 455.436), “In addition to conducting their own ongoing exclusion searches, states should instruct all enrolled Medicaid providers to check their own employees and contractors for exclusions against the LEIE – List of Excluded Individuals and Entities- at the time of hiring and on a monthly basis.”
In response to the federal regulations, the Social Security Death Master File at the time of initial appointment, in addition, MPR will query the LEIE monthly on behalf of any provider covered under a MPR Centralize Verification Service (CVS) agreement. The findings of the LEIE monthly query will be provided to each participating entity in the On-going Monitoring Service (OMS) report.
Medicaid Program Integrity – Toolkits to Address Frequent Findings: 42 CFR 455.436
State Medicaid Director Letter #09-001, dated Jan. 16, 2009
42 CFR 1003.102 Basic for civil money penalties and assessments
42 CFR 1002.3 Disclosure by providers and State Medicaid agencies
NTIS Final Rule on Limited Access Death Master File
If anyone were to ask me what the future of credentialing looks like, I would have to say it can be summed up in one word…collaboration. Without collaboration, the credentialing industry will be unable to move forward. As much as I enjoy seeing health care facilities working together, it’s especially rewarding to see different licensing and accreditation organizations working together.
The Centers for Medicare and Medicaid Services (CMS) and The Joint Commission (TJC) have established standards that permit a hospital to rely on the credentialing and privileging decisions of the entity where the physician is based. This collaboration helps hospitals conserve resources and make needed specialties available to patients. To fully comprehend this collaboration effort we must first understand the terms:
1) Distant Site: Physical location of a practitioner/provider who is remotely seeing a patient or consulting with another provider via telemedicine/teleradiology.
2) Originating Site: The physical location of a patient and/or the patient’s physician/provider during a telemedicine encounter or consult.
3) Telemedicine: The use of electronic communication tools to transmit medical information between distant sites.
4) Telemedicine Entity: Under CMS regulations, a Telemedicine Entity is one that: (a) provides telemedicine services; (b) is not a Medicare-participating hospital; and (c) provides contracted services to a hospital in a manner that enables the hospital to meet applicable Medical Conditions of Participation (CoPs). For example, an organization that provides teleradiology services may be a Telemedicine Entity.
Collaboration in Action
The CMS regulations permit hospitals to grant privileges to telemedicine practitioners based on the credentialing and privileging decisions of a Distant Site hospital or a Telemedicine Entity. This is great news for smaller hospitals overwhelmed by the burden of privileging specialty physicians. In order for the hospital to take advantage of the alternative process permitted by CME, there must be a written agreement with the Distant Site or Telemedicine Entity. The agreement must speak to: (a) credentialing and privileging (The Distant Site hospital must be a Medicare-participating hospital and thus governed by the CoPs related to credentialing and privileging. The Telemedicine Entity must adhere to the CoP requirements for credentialing and privileging as well); (b) list of privileges (The Distant Site – where the practitioner is physically located- must provide the Originating Site – where the patient is physically located – a list of the practitioner’s privileges.); (c) licensing (the telemedicine practitioner at the Distant Site where the provider is located or Telemedicine Entity must hold a license to practice in the state where the patient is located; (d) information exchange – the Originating Site where the patient is located must review the provider’s performance of those services and send to the Distant Site where the practitioner is located performance information for use in the periodic appraisal of the provider.
The board of directors of the Originating Site is where the patient is located, but grants clinical privileges to telemedicine practitioners. What we know about granting privileges is that a Data Bank query is required. The Data Bank query must be performed on behalf of the Originating Site where the patient is located.
Also of importance to note is the different requirements for a Joint Commission accredited hospital. If your facility is Joint Commission accredited, the Distant Site or Telemedicine Entity whose credentialing and privileging decisions are being relied upon must be accredited by the Joint Commission as well.
Hospitals that wish to provide telemedicine services are not required to rely on the credentialing privileging decision of Distant Site hospitals or Telemedicine Entities. Some hospitals may prefer to fully credential and privilege telemedicine practitioner using their standard medical staff process. But, it is nice to know that the opportunity to collaborate with a Distant Site exists in easing the burden of credentialing and privileging.
The old adage “nothing ever stays the same” holds true for us in the field of medicine. One might argue more so than any other chosen professional field. Maintenance of Certification (MOC) is not a new term to those in the field of medical staff services. The introduction dates back to the year 2000 when the 24 Member Board of ABMS agreed to evolve their re-certification programs to one of continuous professional development – ABMS Maintenance of Certification ® (ABMS MOC®).
Rather than sitting for board exams following completion of residency and re-certifying within a specified window for the specific specialty, the ABMS MOC assures that the physician is committed to lifelong learning and competency in a specialty and/or sub-specialty. ABMS MOC requires ongoing measurement of six core competencies. Medical Staff Professionals (MSPs) will recognize these from the Joint Commission Standards.
The Six Core Competencies
Measurement of these competencies happens in a variety of ways, some of which vary according to the specialty. This is carried out by all Member Boards using a four-part process that is designed to keep certification continuous. In 2006, all Member Boards received approval of their ABMS MOC program plans. The boards are now in the process of implementation.
Part I: Licensure and Professional Standing
Part II: Lifelong Learning and Self-Assessment
Part III: Cognitive Expertise
Part IV: Practice Performance Assessment
Although we’ve been introduced to this idea since the beginning of 2000, the challenges still remain on two fronts: 1) the provider and 2) the medical staff services professional (MSPs). The specific challenge for MSPs is in tracking on-going certification.
In a recent conversation with Michael Coyne, ABMS Product Management and Business Development (firstname.lastname@example.org), MPR learned certain boards recommend verifying their diplomats on an annual basis on or near mid-February of each calendar year.
In an effort to keep accurate records on all provider board certifications, MPR will use CertiFacts for primary source verification of all ABMS Board Certification and perform the following:
1) For providers with a lifetime board certification with no “end” date, we will use February 15th as the expiration to check the board certification (via CertiFacts) for renewals.
2) For providers with a Maintenance of Certification (MOC) we will use the re-verification date as the expiration to check the board certification for renewals.
3) For providers with a time limited certification, we will use the expiration date listed on the board certification verification.
This approach should assure we are routinely aware of all board certification expirations and afford us the opportunity to meet our client needs in supplying the most current document for the credential file.
If you would like to read more about the Maintenance of Certification (MOC) process, please contact the American Board of Medical Specialties (ABMS) at http://www.abms.org/maintenance_of_certification/ or contact ABMS Solutions at (800) 722-2267.
On May 6, 2013, The National Practitioner Data Bank (NPDB) and the Healthcare Integrity and Protection Data Bank (HIPDB) merged into one Data Bank. Like any merger, this created a new look and more questions about what was included in the Data Bank reports.
The Data Bank continuous query option continues to be recognized as best practice in the credentialing industry. For further information on the Continuous Query please see the MPR Blog entry Continuous Query Through the National Practitioner Data Bank. The Data Bank posted the following information on their website regarding the merger on May 6, 2013.
- Live Question and Answer Sessions: The Data Bank hosted three live question and answer sessions to address merger topics for Data Bank users. Answers to frequently asked questions can be found in the below Data Bank Merger Q&A Fact Sheet.
- Video Presentation: The Merger of the National Practitioner Data Bank and the Healthcare Integrity and Protection Data Bank: What You Need to Know
- NPDB Merger Final Rule
- Data Bank Merger Q&A Fact Sheet This document will be updated regularly as additional merger questions are received.
What Does the Data Bank Merger Mean for Users?
Essentially, there is no change to the reporting workflow or requirements, but users’ query results may include reports that were not previously available to them. The HIPDB information was integrated into the NPDB, meaning that users who only queried the NPDB may receive expanded access to Data Bank information.
All Queriers: Information previously collected and disclosed through the HIPDB will be collected and disclosed through the NPDB. Users may see Federal and health plan actions/decisions in their query results that they were not able to receive before because they were only available through querying the HIPDB.
- Continuous Query Users: Users may receive notifications for reports (specifically, Federal Government agency and health plan actions/decisions) that were previously unavailable to them.
- ITP and QRXS Users: There are new codes for reporting government administrative actions.
- All Reporters: Reporters have not experienced any changes to reporting, as reporting requirements remain essentially the same. The three primary statutes (Title IV of Public Law 99-660, the Healthcare Quality Improvement Act of 1986, as amended, which established the NPDB; Section 1921 of the Social Security Act, which expanded the NPDB; and Section 1128E of the Social Security Act, added by Section 221(a) of the Health Insurance Portability and Accountability Act of 1996, which established the HIPDB) remain in effect, though modified, and the merger simply combines them into one system.
Specific merger questions can be sent to the NPDB Policy Staff at NPDBPolicy@hrsa.gov. For technical assistance or general questions, please contact the NPDB Customer Service Center at 1-800-767-6732 or email@example.com
When it comes to Medicare, no provider wants to hear revocation. The term revocation has a direct impact on reimbursement and hence the bottom line. In a world where federal funds are always in jeopardy, the idea of having stumbling blocks in reimbursement always gets our attention.
MPR has learned that revocations of Medicare enrollments are occurring for physicians and other providers not only in jurisdictions where providers have previously practiced; but revocations are now occurring for the Medicare enrollments where they currently practice. Revocation is a serious problem resulting not only in termination of a main artery of the revenue stream, but also the debarment of re-enrollment in the Medicare program for no less than one year.
With all the changes in Medicare reimbursement it’s hard to believe this would come as a surprise. But any change in reimbursement deserves attention.
Here is an example. The good news is that MPR can help you become proactive in Medicare reimbursement.
Dr. Jones was in the midst of his fellowship and as required had a valid state license. During his fellowship training, he was enrolled in Medicare Part B in the state jurisdiction to receive Medicare reimbursement for valid services. The problems began when Dr. Jones completed his fellowship. He left the state where he received his training and moved to another state to begin practice. When the time came to renew his license in the state where his training was received Dr. Jones chose not to pursue the renewal. Why would he? He didn’t practice in the state any longer.
When he left his training program, his enrollment with Medicare was not reassigned so Dr. Jones’ enrollment remained active in that state.
Decision point number one; Dr. Jones could have initiated a voluntary termination of his Medicare enrollment, but why would he terminate enrollment in a federal health plan? He was obviously not aware of the Medicare enrollment rules and the implications of the failure to terminate the enrollment.
What we know is that Medicare licensing boards in the states share information with Medical contractors. Following the expiration of Dr. Jones medical license in the state where he was trained, that state’s Medicare contractor received information from the board indicating Dr. Jones’ medical license had expired. The Medicare contractors revoked Dr. Jones’ Medicare enrollment and Dr. Dr. Jones never received communication notifying him of the revocation. After all how would they reach Dr. Jones? They didn’t know how to contact him.
Now we have an enrollment revocation and big problems on the horizon for Dr. Jones. If a provider has an enrollment revoked, they then have an obligation to report this “adverse legal” action to their current Medicare contractor. Dr. Jones was now working in another state and enrolled in Medicare under the new practice in that state. Not being aware of the revocation, he made no disclosure to the state Medicare program where he was currently practicing regarding the revocation of his enrollment in the state where he was trained.
What do we know? Well, we know Medicare contractors are able to share information through the PECOS enrollment system. The Medicare program in the state where Dr. Jones was trained became aware of Dr. Jones revocation due to an expired medical license in this state where he was trained.
Recently Dr. Jones received a letter from the state Medicare program where he was trained indicating his enrollment would be revoked since he not disclose the revocation!
This action resulted in Dr. Jones having to complete a Corrective Action Plan (CAP) to prevent the revocation and is currently in progress. Wow, what a hassle for Dr. Jones. He now has to regularly follow up on the CAP application to insure it is in process and continue the appeals process should it become necessary.
Time spent with Medicare that Dr. Jones could be spending in the delivery of patient care.
What Should You Do to Be Proactive and How Can MPR Help?
1) Check the PECOS enrollment records for your providers to insure there are no revocations listed in PECOS for other Medicare jurisdictions where the provider has worked or trained. MPR can do that for you.
2) If you note a revocation, immediately disclose it to the provider’s current Medicare contractor by completing either a paper enrollment (855I) or a PECOS enrollment. MPR can do that for you.
3) Submit a paper CMS 855I enrollment document to the contractor who revoked the Medicare enrollment requesting a change from “revocation” to “voluntary termination.” Key terms and yes, MPR can help with that. It’s important to note, this will require the actual Medicare PTAN originally assigned to the provider in the previous Medicare jurisdiction. This may be difficult to determine and require the involvement of the provider to contact any and all previous employers (including training programs).
4) KEY: If the enrollment record is not changed from revocation to voluntary termination, this action will ALWAYS need to be disclosed by the provider as an adverse legal action with EVEY Medicare enrollment or re-validation completed by the provider in the future.
What’s the take a-way from this lesson? Whenever you are looking to hire new providers who have been working in other Medicare contractor jurisdictions, get their cooperation to obtain their existing individual Medicare PTANS; and the provider’s PECOS record to be sure there are no current revocations. In addition, be proactive in insuring that any current Medicare enrollments in other Medicare jurisdictions noted in PECOS are voluntarily terminated. The provider’s prior employer or training program may be taking care of the voluntary termination but you need to be sure of this in each case. If you are unable to confirm action taken by the prior employer you need to assure the enrollment is terminated. This will prevent the receipt of that letter of notification of a one-year bar from re-enrollment. Not a good way to begin a practice at a new location.
MPR has a mission to perform all the enrollment paperwork necessary to let the provider devote more attention to seeing patients without the hassle of spending hours attending to paperwork. Let us help you secure the comfort of knowing your enrollment process will be smooth and sustained.
To learn more about revocation read the article by Leslie Witkin at PhysiciansFirst.com.
The initial appointment process requires specific documents to meet accreditation and licensing standards. One of those requirements is a government-issued photo ID. MPR receives this documentation in a variety of different documents including driver’s license, passport and military IDs. Foreign graduates require even more documentation including a J-1, H-B1 Visa and Green Cards. Several different types of visas exist, but these are the two primarily seen in the medical community.
The J-1 visa is a non-immigrant visa. It is issued by the U.S. government for physicians wanting to participate in a medical training experience within the US. All applicants for the J-1 visa must meet eligibility criteria and be sponsored either by a private sector or government program. J-1 visas are issued for a specific period of time and documented on the DS-2019 form. The length of stay for any given J-1 visa is determined by the category of the visa (e.g. alien physician, intern, student, teacher, trainee).
The J-1 visa non-immigrant is subject to a two-year home country physical presence requirement, which requires the individual to return to their home country for at least two years at the end of the exchange visitor program. This is also known as the foreign residence requirements under U.S. law, Immigration and Nationality Act. If the individual is unable to return to the home country to fulfill the two-year requirement, the individual must obtain a J-1 waiver approved by the Department of Homeland Security prior to changing status in the U.S. or being issued a visa in certain categories for travel to the U.S.
There are five bases set in US immigration law under which an individual may apply for a waiver of this requirement. The individual may only apply under one waiver basis to qualify, which they are as follows:
1. No Objection Statement
2. Request by an Interested US Federal Government Agency
4. Exceptional Hardship to a US Citizen (or lawful permanent resident) Spouse or Child of an Exchange Visitor: and
5. Request by a Designed State Public Health Department or its Equivalent
Dependents of a J-1 non-immigrant (spouse and/or children) are classified as J-2 visa non-immigrants. They are subject to the same laws and requirements of the J-1 visa non-immigrant but are not required to make a separate waiver request. They are automatically put under the J-1 non-immigrant’s application for waiver.
In 2011, new regulations were issued requiring a job offer prior to a visa interview for student visas from Bulgaria, Russia, Romania, Ukraine, Moldova and Belarus.
The H-1B visa is a non-immigrant visa. It is issued by the United States under the Immigration and Nationality Act, section 101(a)(15)(H) and allows US employers to temporarily employ foreign workers in specialty occupations. The regulations define a “specialty occupation” as requiring theoretical and practical application of a body of highly specialized knowledge in a field of human endeavor including but not limited to biotechnology, chemistry, medicine and health. Foreign applicants must possess at least a bachelor’s degree or its equivalent and state licensure, if required to practice.H-1B work-visas are limited to employment by a sponsoring employer. H-1B visas are limited to a three-year stay, extendable up to six years.
A Green Card holder (permanent resident) is someone who has been granted authorization to live and work in the United States on a permanent basis. As proof of that status, a person is granted a permanent resident card, commonly called a “Green Card.” You can become a permanent resident several different ways. Most individuals are sponsored by a family member or employer in the United States. Other individuals may become permanent residents through refugee or asylee status or other humanitarian programs. In some cases, you may be eligible to file for yourself. The application process can start after the individual receives the J-1 wavier approval.
A green card is issued to all permanent residents as proof that they are authorized to live and work in the United States. If you are a permanent resident age 18 or older, you are required to have a valid green card in your possession at all times. Current green cards are valid for 10 years, or 2 years in the case of a conditional resident, and must be renewed before the card expires.
The last stage of immigration is the path to U.S. Citizenship. If you are a green card holder of at least 5 years, you must meet the following requirements in order to apply for naturalization:
Be 18 or older at the time of filing
• Be a green card holder for at least 5 years
• Have lived within the state, or USCIS district with jurisdiction over the applicant’s place of residence, for at least 3 months prior to the date of filing the application
• Have continuous residence in the United States as a green card holder for at least 5 years immediately preceding the date of filing the application
• Be physically present in the United States for at least 30 months out of the 5 years immediately preceding the date of filing the application
• Reside continuously within the United States from the date of application for naturalization up to the time of naturalization
• Be able to read, write, and speak English and have knowledge and an understanding of U.S. history and government (civics).
• Be a person of good moral character, attached to the principles of the Constitution of the United States, and well disposed to the good order and happiness of the United States during all relevant periods under the law
Regardless of the type of visa that an individual holds, there are different expirations for each type. MPR will identify these documents at the time of initial appointment and update the files upon reappointment. If a provider is identified with an expired Visa or Green card, MPR will notify all applicable participating health care facilities.
I’m often asked credentialing questions about allied health providers and the questions are valid because allied health providers have come onto the healthcare scene with a prominent presence. Every state has different laws and parameters for the scope of practice of allied health providers. The parameters identify what level of providers are Licensed Independent Providers (LIPs) or licensed dependent providers. Independent providers are able to practice without physician supervision while dependent providers require physician supervision. The level of credentialing is not based upon the definition recognized by the state. The level of credentialing required of any provider depends on what level of care the facility is permitting that provider to practice within the facility. For example, if social workers are licensed to practice independently, but within the facility they are required to practice with physician supervision, then they may be credentialed as dependent practitioners.
Another level of allied health providers has recently emerged. This level is called Advanced Practice Providers (APPs). Typically these providers are allowed to practice independently and thus are granted clinical privileges. If a “medical level of care” has been defined by the facility, the providers must be granted clinical privileges. CMS has never defined a “medical level of care.” CMS has stated that it includes functions performed by Physician Assistants (PA) and Advance Practice Registered Nurses (APRN) as those requiring clinical privileges and hence credentialing. Thus, PAs and APRNs must be credentialed and granted privileges through the Medical Staff process, regardless of whether they are employed by the hospital or by a private physician.
Where does this leave us with other providers (RNs, dental assistants, ophthalmic assistants, scrub techs, etc.). The credentialing accreditation and licensing standards defer the judgment to the individual facility. Some facilities are adopting the term Certified Assistants or CAs. The depth of verification is specific to each facility. However, basic data sets are similar in requiring licensure/registration/certification and insurance.
I am certain we will continue to see more and more allied health providers on the healthcare scene. Credentialing these providers will require a thoughtful approach to the requirements adopted. I look forward to this credentialing challenge as we continue to shape the requirements. The credentialing file is, after all, the first line of defense in patient care.
Physicians who received their basic medical degree from a school outside the United States and Canada (international medical graduates or IMGs) make up roughly 25% of physicians in training and practice in the United States. Certification by the Education Council for Foreign Medical Graduate (ECFMG) is the standard for evaluating the qualifications of these physicians before they enter U.S. graduate medical education (GME), where they provide supervised patient care and it is recognized by the Joint Commission as primary source verification of foreign education.
Evaluating the readiness of IMGs to enter graduate medical education (GME) programs in the United States has long been a concern of medical organizations, hospitals, state licensing agencies, and the public. During the 1950s, the need for a formal program of evaluation intensified due to explosive growth in the demand for health care services, an increase in economic opportunities for trained medical personnel, and a greater dependence on residents to provide medical care, which created a large number of available positions in U.S. GME programs.
In 1956, a private, nonprofit organization, the Education Council for Foreign Medical Graduate (ECFMG), was established to:
- Provide information and to answer inquiries of IMGs planning to come to the United States for GME
- Evaluate IMGs’ credentials, knowledge of medicine, and command of English
- Certify that IMGs have met certain medical education and examination requirements.
The ECFMG exam is three-step process in assessing 1) clinical skills. 2) verbal communication skills, and 3) United States Medical Licensing Examination (USMLE) to obtain an unrestricted license to practice medicine in the United States.
MPR uses electronic verification of the ECFMG as primary source verification for education attained on foreign soil by a physician. Written verification requests are sent to secure the training attained on foreign soil.
Although the electronic verification of foreign education has reduced the turn-around-time for primary source verification of foreign graduates, the verification of training remains a challenge. The majority of accredited and licensed health care facilities accept verification of training provided in the United States or verification of a 5th pathway to establish medical staff membership and clinical privileges. Regardless, each foreign graduate application is evaluated and verified according to education and training received to establish documentation of current clinical competency.
Medical Provider Resources entered into an agreement with Via Christi Health Systems to provide system-wide credentialing services effective Feb. 1. The new agreement means MPR will conduct
primary credential verification for all providers and allied health staff seeking practice privileges at Via Christi’s hospitals. The completed file then will be shared among all the Via Christi’s Wichita hospitals,
including Via Christi Rehabilitation Hospital. Plans are to expand MPR’s credentialing model to Via Christi’s hospitals in Pittsburgh and Manhattan.
“At Via Christi, we are moving toward our vision of greater efficiency, more centralized and simplified credentialing, and getting physicians and allied health providers on board more quickly. To accomplish this, we have formed a closer working partnership with Medical Provider Resources,”said Steve Nesbit, DO, chief medical officer, Via Christi Hospitals in Wichita.
In the past, completing three different applications was required if a physician or allied health provider, such as a nurse or physical therapist, wanted practice privileges at Via Christi hospitals on
St. Francis and Harry (which operate under a single license), Via Christi Hospital on St. Teresa and Via Christi Rehabilitation.
“With this new working relationship, providers simply request and complete one application. It’s a win for the provider, a win for Via Christi and a win for MPR,” said Vicki Bond, MPR’s chief
The goal of this MSSC-operated entity is to deliver best practice services that help physicians and hospitals efficiently respond to the growing demand for credentialing information and other practice management requirements. Other MPR services available include insurance plans and Medicare/Medicaid enrollment, Kansas licensure renewal and DEA registration or renewal.