Transcript Credentialing, Accreditation, and Certification

Credentialing, Accreditation, and
Certification:
What the Radiologist Needs to Know
A Special Thank You to:
Dr. David M. Yousem, M.D., M.B.A. Professor, Department of
Radiology Vice Chairman of Program Development Director of
Neuroradiology Johns Hopkins Hospital
for allowing the use of his material/content in this presentation
Dr. Yousem’s online lecture series can be viewed at:
http://webcast.jhu.edu/mediasite/Catalog/pages/catalog.aspx?catalogId
=7e18b7d5-9c63-487e-aaf1-77a86f83b011
Dr. Yousem’s project was funded through an RSNA Educational Grant
In this presentation we will discuss:
1. What is Credentialing? Who provides it and why is it needed?
2. What is Accreditation? What is it important?
3. What is Certification and Maintenance of Certification? How and
when is it obtained?
What is Credentialing?
• Credentialing is a systematic review process used by a hospital
or managed care organization (MCO) to assess and confirm that
a physician is competent and qualified to practice medicine in
their designated field
• The landmark Darling v.Charleston Hospital case in the 1960’s
established that hospitals had an obligation to verify the
competency of the physicians who practice within its walls, and
thus credentialing was born
Credentialing Committee
• Each hospital or MCO will have their own credentialing
committee
• The committee is composed of various health care workers:
doctors, nurses, physician assistants, administrators, etc. Having
a radiologist on the committee is ideal since the committee
determines the criteria necessary to grant specific privileges to
individual physicians
• The committee also collects, reviews, and verifies various
documents to ensure that a physician meets 6 core
competencies: medical knowledge, technical skills, clinical
judgment, interpersonal skills, communication skills, and
professionalism.
Credentialing Support Databases
• Committees can use various credentialing support services to verify
physician information:
– National Practitioner Data Bank:
• Provides information regarding malpractice claims,
restrictions of privileges, professional society adverse
sanctions, licensure actions by state boards, DEA reports,
and CMS exclusion actions. Check your status at
www.npdb-hipdb.hrsa.gov
– Healthcare integrity and Protection databank:
• Discloses any fraudulent Medicare or Medicaid claims
American
– Board of Medical Specialties:
– DEA, CDS, Centers for Medicare and Medicaid Services (CMS)
Delay or Denial of Credentialing
• There are particular RED FLAGS that can delay or deny
credentialing:
– Personal conduct history
- Poor references
– Deferred letters
- Alcohol or substance abuse
– Multiple malpractice suites
- Short employment periods
– Unexplained gaps in employment or education
• If there is a high risk that credentialing will be denied, it is in the best
interest of the physician to resign before the committee investigates
or makes their conclusion, as this denial of credentialing will remain
on the physician’s permanent record
Delineation of Privileges
• The Credentialing committee also determines each physicians
privileges depending on their specific training and skill level
• For example, the committee can specify the minimum number of
CT, MR, US, myelograms, biopsies, etc that must be read or
performed in a specific amount of time to obtain/maintain specific
privileges
– Again, it is important for a radiologist to be on the committee
to help determine these criteria
• These criteria ensure physicians, both radiologist and nonradiologist, are competent in their areas of care
Recredentialing
• Once credentialed by a hospital, a physician must apply for
recredentialing every 2 years to maintain their privileges
Why is Credentialing Important?
• A physician MUST be credentialed by a hospital to work there
• Part of credentialing is delineation of privileges for every hospital
staff member, ensuring a physician’s competence in their
particular skill set
What is Accreditation?
• Accreditation of a health care facility ensures that it is
maintaining a high standard for the quality and safety of health
care delivery
• The Joint Commission (formerly the Joint Commission
Accreditation of Healthcare Organizations - JACHO) or the
American Osteopathic Association (AOA) has the ability to
accredit hospitals
– Periodic inspections and reviews
• The National committee for Quality assurance (NCQA) is a
nongovernment agency that accredits MCO, PPOs, health plans,
etc
• The American College of Radiology (ACR) accredits imaging
facilities
ACR Accreditation of Imaging Facilities
• ACR sets protocols and guidelines for imaging facilities to ensure
image quality, equipment, and reporting meet the highest
standards in quality and safety
• ACR evaluates the imaging equipment and the physician in a
practice setting
• This includes radiologists and non-radiologist imagers such as
cardiologists, orthopedists, chiropractors, or any physician using
imaging equipment in their practice
ACR Accreditation
• Factors evaluated by the ACR:
– Image quality
– Film storage and handling
– Patient identification
– Right and Left marker placement
– Written reports
– Frequency of equipment inspection
Why is ACR Accreditation Important?
• It not only ensures the quality of imaging and reporting but is also
REQUIRED by some insurers to be reimbursed
• Accreditation also restricts non-radiologist from obtaining
inadequate images or from obtaining images but not providing
written reports
• More information regarding ACR accreditation can be found on
their website, www.acr.org
What is Certification?
• Certification is a lifelong process by which the ABR and/or
ABMS ensures that you, as a radiologist are adequately qualified
and are involved in continued learning and improvement
• There are two certification processes, both of which are awarded
by the ABR:
– Initial certification
– Maintenance of Certification (MOC)
To Apply for Initial Certification you must have:
• 5 years of approved training
– 1 year clinical
– 4 years in Diagnostic Radiology, which includes 4 months of
Nuclear Medicine, 3 months of Mammography, and no more
than 12 months in any one discipline
• Passed all ABR examinations
– Currently: Physics, Written, and Oral Examinations
– For the 2012 class and forward: a Core examination during R3R4 year and Certifying examination 15 months after R4 year
• Cardiac life support certification, high moral and ethical standards,
and proof of valid state licensure or Canadian equivalent
Certification and Recertification
• You have a 10 year period after completing training in which to
obtain initial certification, which is valid for 10 years
• You must then apply for Recertification through the ABR and/or
American board of medical specialties (ABMS) to continue
practicing as a radiologist
MOC: Recertification
• To become recertified, you must practice radiology, maintain an
active unrestricted license and professional standing, pass the
Maintenance of certification (MOC) exam, and meet the following
specific requirements over a 10 year period:
– 250 CME credits
– MOC exam
- 20 SAM
- 3 PQI projects
Specific Recertification Requirements: A Closer Look
• 250 category 1 CME credits
– 70% in a subspecialty or area of practice, 30% general
• 20 SAM (self assessment modules, each is 90 min)
– 4 SAM must be in general knowledge, 16 in clinical content
– At least 6 need to be subspecialty specific
– May overlap with the CME requirement
– SAM can be found on the ACR or subspecialty websites
• MOC examination
– Comprehensive 4 hr knowledge based computer test
• 80% clinical content, 20% non-interpretive skills including
safety, life support, ethics, physics
Specific Recertification Requirements: A Closer Look
•
3 PQI (Practice Quality Improvement) projects in 10 years
– PQI project is a means of self-evaluation and continued quality
improvement
– The project must be in one of these five areas: patient safety,
accuracy of interpretation, report timeliness and critical value
reporting, referring physician services, practice guidelines.
– PQI projects can be designed by an individual radiologists, radiology
practice groups or departments, institutions, healthcare systems, or
by professional radiology societies
– Every radiologist participating may receive PQI credit for the project
More PQI information can be found at www.theabr.org
Summary
• Credentialing is hospital based process which ensures physician
competence and delineates physician privileges
• Accreditation of a facility by the ACR assures imaging quality
standards and is required for insurance reimbursement
• Certification and MOC by the ABR ensures that radiologists are
involved in continuous learning and self-improvement
References
• www.theabr.org
• www.acr.org