By: Ray Jorgensen, Co-Founder, PMG Credentialing

Normally, this column provides anecdotal lessons from best or worst practices seen in the health center field over the last 20 plus years. With too many health care professionals interchangeably using the words credentialing and enrollment, this article offers clarity with focus on HRSA’s Health Center Compliance Manual, Chapter 5: Clinical Staffing.  

Enrollment is the process of obtaining participating provider status with a governmental or commercial payer. Credentialing is either obtaining privileges for a provider at a facility (e.g., hospital or nursing home) OR what HRSA requires each health center to do for each employed provider.

HRSA says a “[health center… [must have] …operating procedures for the initial and recurring review (for example, every two years) of credentials for all clinical staff members.” I.e., during (prior to) hiring health centers must vet staff based on requirements in Chapter 5. Many providers are not even enrolled with health plans for months after their first day seeing patients, so it seems reasonable to ask if this initial Credentialing is happening. One PMG team member calls this delayed process Negligent Credentialing.

In the Glossary of the HRSA Health Center Compliance Manual, Credentialing is defined as: “The process of assessing and confirming the license or certification, education, training, and other qualifications of a licensed or certified health care practitioner.” This means a health center must assure an employed or contracted provider (what HRSA calls LIPs (Licensed Independent Practitioners) or OLCPs (Other Licensed or Certified Practitioners) meet all regulatory licensing requirements.

Most of the language below is quoted or paraphrased from the HRSA manual. When you see “NOTE:” this is an editorial comment from the author.

By mandate, these Credentialing requirements must include:

• Primary Source Verification (PSV) of current licensure, registration, or certification. 
  NOTE: HRSA defines Primary Source (again in the Glossary) as “verification by the original source of a specific credential of the accuracy of a qualification reported by an individual health care practitioner. In other words, a health center must contact medical schools, DEA source, and other original places of education, training, certification, etc. 

• Education and training for initial credentialing, using:

  • Primary sources for LIPs 
    NOTE: Footnote #4 says if a state medical society attests to doing PSV for all medical society members, a health center doesn’t have to also do PSV.

  • Primary or other sources (as determined by the health center) for OLCPs and any other clinical staff;
    NOTE: Italics added for emphasis BUT a health center should have written policy on what sources are or are not permissible.

• Completion of a query through the National Practitioner Data Bank (NPDB)
  NOTE: Footnote #5 provides a link to this site which details info on medical malpractice and adverse claims.

• Clinical staff member’s identity for initial credentialing using a government-issued picture identification;
  NOTE: Health centers, in a compliance manual should document what government issued forms are acceptable.

• Drug Enforcement Administration (DEA) registration; and

• Current documentation of basic life support training.
  NOTE: For these last two, health center compliance manuals should indicate which staff person/department owns this and frequency of verification.

The next section is about not initial evaluation of a LIP or OLCP but Privileging and bi-annual (i.e., every two years), renewal. Privileging is defined in the HRSA Compliance Manual Glossary as “The process of authorizing a health care practitioner’s specific scope and content of patient care services.“ Remember documented operating procedures for this work is required. Further, Privileging must happen for health center employees, individual contractors, or volunteers. 

Privileging procedures must address the following: 

• Verification of fitness for duty, immunization, and communicable disease status.
  NOTE: Footnote #6 discusses minimum requirements in this regard and CDC recommendations. 

• For initial privileging, verification of current clinical competence via training, education, and, as available, reference reviews.
  NOTE: Health centers should document for providers minimum requirements in this regard.

• For renewal of privileges, verification of current clinical competence via peer review or other comparable methods (E.g., supervisory performance reviews); and

• There must be a process for denying, modifying or removing privileges based on assessments of clinical competence and/or fitness for duty.
  NOTE: This means ongoing evaluation of providers by the health center to assure they meet minimum standards for taking care of patients. A health center must be able to prove this work is happening on an ongoing basis.

The health center maintains records for its clinical staff (E.g., employees, individual contractors, and volunteers) that contain documentation of licensure, credentialing verification, and applicable privileges, consistent with operating procedures.

NOTE: At PMG, we use a powerful software that maintains all current data for all health center providers AND uses bots to automatically check status for licensure, certification, etc. Where data cannot be verified via automated fashion, phone or email contact is utilized and documented.

• If the health center contracts with provider organizations (E.g., group practices, locum tenens staffing agencies, training programs) or formal, written referral agreements with other provider organizations that provide services within its scope of project, the health center ensures that such providers are: Licensed, certified, or registered as verified through a credentialing process, in accordance with applicable Federal, state, and local laws; and 

• Competent and fit to perform the contracted or referred services, as assessed through a privileging process.
  NOTE: HRSA’s Footnote #7 via example suggests contractual provisions address the need for the contractor to do this work OR expects the health center to manage for contracted staff. The point is the process must be documented. 

While the above is officious, it is doable. The real question is whether your health center is doing all that is required by HRSA. It is tedious but painfully clear what is required. If you have questions regarding the process or your ability to sustain successful credentialing and enrollment, contact PMG to learn how we can help keep you compliant and maximize each provider’s billable opportunity. We are just a phone call or email away.