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Healthcare entities have the responsibility to guarantee the best service to their clients. This is done by developing rules and standards which the staff must follow, delivering the best care possible to patients, responding to the needs of the community, allocating resources most effectively, and creating procedures that allow medical staff members to provide adequate service with the highest quality.

Hospitals, both public and private, have the same core responsibilities regarding their medical staff. The governing body of the hospital (i.e., its board of directors), and any committee to which it delegates authority, is responsible for both credentialing/privileging its medical staff, and implementing a timely, fair and thorough peer review process.

In this seminar, attorney Eric Boughman addresses the fundamentals of medical credentialing and privileging, the process of assessing and validating qualifications, the competence of licensed practitioners, peer review processes, and the evaluation and disciplinary process of staff doctors.

In discussing medical credentialing, Eric will discuss the importance, for healthcare entities and medical practitioners, of knowing and understanding the process needed to be able to perform procedures or treat patients. To become a member of the hospital’s medical staff, the medical practitioners generally must apply for membership. After such an application is accepted, it must go through the credentialing and privileging process. This process validates that physician has the required qualifications, training, and experience for medical staff membership.

Although details of the medical credentialing process vary depending upon the facility, location, medical specialties, and particular circumstances involved, in this section attendees will learn how the general process is carried out.

From a credentialing requirement perspective, we will cover the importance of a well-defined and transparent credentialing and privileging process. We will discuss the new ways in which hospitals and other healthcare organizations are collecting and verifying most of the information required from practitioner applicants.

Credentialing is one of the first steps residents and fellows completing their medical training must take to practice as independent or attending physicians. The credentialing process can be very lengthy and involves an extensive credentialing application. One of the most significant issues that often arise in credentialing is when incomplete or inaccurate information is provided by the applicant or their prior institution/employer. Since this type of situation causes delays and often a lot of time-consuming back-and-forth coordination, attendees will learn some helpful tips and tricks to go over this process successfully.

Eric will also discuss the peer review process. The traditional peer review process in the hospital setting is the evaluation by other physicians of the appropriateness and quality of care provided by an individual physician, generally by other physicians on the same hospital medical staff as the physician being evaluated.

Finally, we will discuss the peer review procedures safeguards, the hearing process, insurance credentialing, and important recommendations. Attendees will gain insight into the credentialing and peer review process and pick up useful pointers and methods for navigating these procedures successfully.

Learning Objectives:

• Understanding the medical staff credentialing.
• Identifying the general process for credentialing.
• Knowing the credential requirement.
• Knowing credentialing tips and tricks.
• Understanding the governing documents.
• Understanding the peer review process.
• Identifying the peer review procedural safeguards.
• Understanding the peer review hearing process.

Areas Covered in the Session

• The general process to vet a medical practitioner’s application.
• Medical staff credentialing and privileging.
• Credential process requirement.
• Credentialing tips and best practices.
• Documents governing the organizations.
• The peer review process and requirements.
• Peer review procedural safeguards – HCQIA (Federal Law)
• Peer review hearing process
• Recommendations

Suggested Attendees

• Healthcare providers and staff.
• Hospital and healthcare facility administration.
• Vendors and contractors who work in the healthcare sector.
• Legal counsel and other professional advisors to healthcare providers.
• Credentialing and Enrollment Specialists
• Healthcare Administrative Personnel
• Practice Managers
• Healthcare Billing Specialist
• Clinic Managers

About the Presenter