The Licensure and Certification Policy, QM

The Licensure and Certification Policy, QM

DEPARTMENT: Quality Standards / POLICY DESCRIPTION: Licensure and Certification
PAGE:1 of 7 / REPLACES POLICY DATED: Feb. 2, 2000;
Jan.1, 2001; April 1, 2001; Feb. 15, 2002
APPROVED: July 9, 2002 / RETIRED:
EFFECTIVE DATE: August 1, 2002 / REFERENCE NUMBER: QM.002
SCOPE: All Company-affiliated facilities including, but not limited to, hospitals, ambulatory surgery centers, home health agencies, physician practices, and all Corporate Departments, Groups and Divisions. Specifically, the following departments:
Human Resources Quality Standards/Management

Administration Internal Audit and Consulting

Medical Staff Services Risk Management
Ethics and Compliance Legal

Admitting/Registration Health Information Management Services

Business Office Information Services

Revenue Service Center Medicare Service Center

Reimbursement Governmental Operations Support

PURPOSE: To ensure that Company affiliates, physicians, privileged practitioners and independent or dependent practitioners or contractors who provide and/or order services which require licensure, certification or other credentials have valid licenses, certificates or credentials and are not ineligible persons.
To ensure that no Federal health care program payment is sought for any items or services directed or prescribed by a physician, privileged practitioner or independent or dependent practitioner or contractor who provides and/or orders services who is an ineligible person.
To ensure that each Company-affiliated facility conduct appropriate checks as to licensure at the time of appointment, prior to licensure expiration dates and at least every 2 years thereafter for privileged practitioners and upon ordering tests or services and at least every 2 years thereafter for non-privileged practitioners.
To ensure that each Company-affiliated facility conduct appropriate checks as to exclusion status at the time of appointment and at least every 6 months thereafter for privileged practitioners and at the time of ordering tests or services and at least every 6 months thereafter for non-privileged practitioners.
POLICY:
1.All Company-affiliated facilities must have written policies and procedures that address issues related to licensure, certification, registration, or other credentials of affiliates, physicians, privileged practitioners, and independent or dependent practitioners or contractors providing and/or ordering services which require a license, certificate, registration, and/or other credentials.
2.All privileged practitioners and independent or dependent practitioners or contractors providing services at Company-affiliated facilities must comply at all times with Federal, State and professional requirements applicable to their respective discipline.
3.Each Company-affiliated facility must:
  1. Maintain documentation to demonstrate proof of valid licenses and certificates as appropriate, and
  2. require notice from each colleague, affiliate, physician, privileged practitioner and independent or dependent practitioner or contractor of any revocation, suspension or investigation of licensure and/or credential status or his/her status as an ineligible person.
  1. A colleague, affiliate, physician, privileged practitioner, or independent or dependent practitioner or contractor who provides and/or orders services in a Company-affiliated facility must have valid, current licenses or credentials in the state in which the facility is located, unless otherwise authorized by applicable state law and identified on the Company’s intranet at:
or the licensed healthcare professional is a member of the Armed Forces. A licensed healthcare professional who is a member of the Armed Forces may practice the member’s profession in any state, regardless of whether the practice occurs in a healthcare facility of the Department of Defense, a civilian facility affiliated with the Department of Defense, or any other authorized location as long as the individual is practicing within the scope of Federal duties.
Note: The referenced intranet site includes summaries of state laws that permit some latitude with regard to licensure issues. It also includes guidelines for facilities in states with such laws.
  1. Each Company-affiliated facility must ensure that Federal Health Programs are not billed for any services, tests or treatments rendered based upon the order or direction of a physician or other practitioner who is an ineligible person.
  1. Prior to initially granting or renewing privileges, each Company-affiliated facility must search the HHS/OIG List of Excluded Individuals/Entities (the “OIG Sanction Report”) and the General Service Administration’s List of Parties Excluded from Federal Programs (the “GSA List”) to ensure that no colleague, affiliate, physician, privileged practitioner, or independent or dependent practitioner or contractor is an ineligible person.
  1. Each Company-affiliated facility also must ensure that all physicians and other practitioners who do not possess facility privileges, but who order services from the facility, are properly licensed to do so and are not an ineligible person.
  2. Each Company-affiliated facility must conduct appropriate checks as to licensure at the time of appointment, prior to licensure expiration dates and at least every 2 years thereafter for privileged practitioners and upon ordering tests or services and at least every 2 years thereafter for non-privileged practitioners.
  1. Each Company-affiliated facility must conduct appropriate checks as to exclusion status at the time of appointment and at least every 6 months thereafter for privileged practitioners and at the time of ordering tests or services and at least every 6 months thereafter for non-privileged practitioners.
  1. Each Company-affiliated facility must have procedures in place (see attached Implementation Guidelines, Flowchart and Implementation Checklist) to ensure that no Federal health care program payment is sought for any items or services directed or prescribed by a physician, privileged practitioner or independent or dependent practitioner or contractor who provides and/or orders services who is an ineligible person.

Definitions

Allied Health Practitioner – Any non-physician practitioner permitted by law to provide care and services within the scope of the individual’s license and consistent with individually granted clinical privileges by the Board of Trustees. For example, certified nurse-midwives, certified registered nurse anesthetists, clinical psychologists, clinical social workers, physician assistants, nurse practitioners, and clinical nurse specialists.
Certification – The procedure and action by which a duly authorized body evaluates and recognizes (certifies) an individual as meeting predetermined requirements.
Department of Health and Human Services (HHS)/OIG List of Excluded Individuals/Entities– The Department of Health and Human Services' Office of Inspector General's (OIG) List of Excluded Individuals/Entities provides information to health care providers, patients, and others regarding individuals and entities that are excluded from participation in Medicare, Medicaid, and other Federal health care programs.
Dependent Practitioner – An individual who is permitted by law and the Company-affiliated facility in which he/she practices to provide patient care services under the direction or supervision of an independent practitioner, within the scope of the individual's license and in accordance with individually granted clinical privileges.
Federal Health Care Program – Any plan or program that provides health benefits, whether directly, through insurance, or otherwise, which is funded directly, in whole or in part, by the United States Government or a State health care program (with the exception of the Federal Employees Health Benefits Program) (section 1128B(f) of the Social Security Act). The most significant Federal health care programs are Medicare, Medicaid,Blue Cross Federal Employee Program (FEP)/ Tricare/Champus and the Veterans programs.
General Service Administration’s List of Parties Excluded from Federal Programs – The List of Parties Excluded from Federal Procurement and Nonprocurement Programs ("List of Parties") identifies those parties excluded throughout the U.S. Government (unless otherwise noted) from receiving Federal contracts or certain subcontracts and from certain types of Federal financial and nonfinancial assistance and benefits. The List of Parties is maintained by the U.S. General Services Administration (GSA) for the use of Federal programs and activities.
Independent Practitioner – An individual who is permitted by law and by a Company-affiliated facility in which he/she practices to provide patient care services without direction or supervision, within the scope of the individual's license and in accordance with individually granted clinical privileges.

Ineligible Person – Any individual who: (1) is currently excluded, suspended, debarred, or ineligible to participate in any Federal health care program; or (2) has been convicted of a criminal offense related to the provision of health care items or services and has not been reinstated in a Federal health care program after a period of exclusion, suspension, debarment, or ineligibility, provided that the Company is aware of such criminal offense.

License – An official or a legal permission, granted by competent authority, usually public, to an individual to engage in a practice, an occupation or an activity otherwise unlawful.
Licensure – A legal right that is granted by a governmental agency in compliance with a statute governing the activities of a profession.
Non-Privileged Practitioner – Those individuals who are licensed in the state of the Company-affiliated facility to order specific tests and services but who are not medical staff members or privileged practitioners by the Company-affiliated facility.
Physician – A doctor; a person who has been educated, trained, and licensed to practice the art and science of medicine.
Privileged Practitioner – A person who practices medicine (physician) or one of the allied health professions who has been granted by an appropriate authority of a Company-affiliated facility, such as the board of trustees, the authority to provide specific patient services within defined limits.
Privileges – Authorization granted by an appropriate authority, such as the board of trustees in a Company-affiliated facility, to a practitioner to provide specific patient services in the facility within defined limits, based on an individual practitioner's license, education, training, experience, competence, health status, and judgement.
Registration – The process in which a person licensed to practice by a state authority has such license recorded or registered.
PROCEDURE:
  1. Each facility must establish policies, bylaws or contractual agreements defining licensure and certification requirements for the facility, departments and services, colleague positions, physicians, privileged practitioner and independent and dependent practitioners or contractors (i.e., Allied Health Professional policies, Medical Staff credentialing policies).
  1. Each facility shall work with its Medical Executive Committee to develop enforcement remedies and disciplinary procedures that address infractions of the facility’s Licensure Verification and Certification policy.
  1. Each facility should require processes to review and validate licensure, certification or other credentials for privileged practitioners based upon issues such as the following:
  • Licensure or certification maintenance requirements such as:
  • Mandatory continuing education
  • State specific minimal census requirements
  • Maintenance of required minimum limits of professional liability coverage
  • Annual performance/competency assessments
  • Voluntary or involuntary relinquishment or reduction of credentials
  • Licensure or certification expiration dates
  • Previously successful or currently pending challenges to any licensure or certification
  1. Each facility must check licensure and certification status as follows:
  1. Following the procedures in Attachment A, prior to granting privileges, prior to licensure expiration dates and at least once every two years thereafter, each Company-affiliated facility must verify that the practitioner has a valid license, certificate or credential. Should an individual not have a valid license, certificate or credential, the facility must follow the applicable procedures as defined by the Medical Staff Bylaws, Rules and Regulations for discontinuing credentialing or canceling privileges.
  1. Following the procedures in Attachment A, at the time of receiving an order, prior to licensure expiration dates and at least once every two years thereafter, each Company-affiliated facility must verify that the ordering practitioner has a valid license, certificate or credential. Should an individual not have a valid license, certificate or credential, the facility must follow the steps outlined in Attachment A for prohibiting such individual from ordering further services.
  1. Each facility must check exclusion status as follows:
a)Following the procedures in Attachment A, prior to granting privileges, and at least once every six months thereafter, each Company-affiliated facility must compare the name and address of each colleague, affiliate, physician, privileged practitioner and independent or dependent practitioner or contractor providing and/or ordering services at the facility to the OIG Sanction Report and the GSA List to ensure that those individuals are not ineligible persons. The OIG Sanction Report and the GSA List are available in searchable formats on the Internet at, respectively: and Should an individual appear on the OIG Sanction Report or the GSA List, the facility may not grant privileges for that individual until the charges are resolved and it is clear that the individual is not excluded, suspended or debarred. Should an individual submit the attached affidavit that he/she is not the individual that appears on the GSA List, the process for granting privileges may continue for that individual.
  1. Following the procedures in Attachment A, at the time of receiving an order and at least once every six months thereafter, each Company-affiliated facility also must compare the name and address of each physician or other practitioner who does not possess facility privileges, but who orders services from the facility, against the OIG Sanction Report and the GSA List to ensure that such physicians or other practitioners are not ineligible persons. Should such a physician or other practitioner appear on the OIG Sanction Report or the GSA List, the facility shall no longer permit such physician or other practitioner to order services from the facility (unless the physician or other practitioner can provide satisfactory evidence that he/she is not the individual that appears on the OIG Sanction Report or the GSA List).
c.Each incident of a physician’s or other practitioner’s confirmation as an Ineligible Person must be reported to the facility Ethics and Compliance Officer (ECO) and Division Reimbursement Manager to address potential cost reporting issues. The ECO will report each such incidence to the Director, CIA Implementation, and on the facility’s next ECO Quarterly Report.
d.Documentation:
  1. Checks prior to granting (or renewing) privileges or initially accepting orders for tests or services from non-privileged practitioners: The Search Results screens must be printed and copies must be maintained by the facility, whether or not the results indicate a match. Such copies may be maintained in the hospital’s physician file or in a master exclusion verification file, filed by year and alphabetized.
  2. Semi-annual checks: The search results must be documented (e.g., on a checklist of physicians) and should be maintained in a master exclusion verification file. If the search indicates a possible match, the Search Results screens must be printed and copies must be maintained in the hospital’s physician file or in a master exclusion verification file filed by year and alphabetized.
  3. Employed physicians: Documentation of periodic search results of employed physicians (done by Corporate IT&S quarterly in the search against the Company employee database) is maintained by IT&S. The facility is required to maintain documentation as required by the Limitations on Employment Policy, HR.209.
  4. All documents pertaining to an incidence in which a listed individual or company is confirmed to be an Ineligible Person must be maintained for a minimum of five (5) years.
  1. Each facility must retain the documentation generated as a result of the procedures regarding licensure, certification or other credentials set forth herein in accordance with records retention schedules developed pursuant to the Company’s Records Management Policy, EC.014.
It is the responsibility of the facility CEO or facility Administrator to ensure adherence to this policy.
REFERENCES:
LEXICON, Dictionary of Health Care Terms, Joint Commission on Accreditation of Healthcare Organizations (“JCAHO”), One Renaissance Boulevard, Oakbrook Terrace, Illinois, 1994
Steadman’s Concise Medical & Allied Health Dictionary, 1997
Comprehensive Accreditation Manual for Hospitals, JCAHO, 1999
42 U.S.C. § 1320a-7a(a)(6)
42 C.F.R. § 1003
63 Fed. Reg. 46676

Limitations on Employment Policy, HR.209

Prohibition Against Contracting with Any Ineligible Person Policy, MM.001

Records Management Policy, EC.014
American Medical Association Physician Licensure: An Update of Trends,

Implementation Guidelines Attachment A

Licensure and Certification Policy, QM.002

The following guidelines were developed to assist in the implementation of the Licensure and Certification Policy, QM.002, as it relates to physician and/or allied health practitioner licensure and certification. Please ensure the policy has been read closely before proceeding.

Prior to billing for tests or services ordered by physicians or allied health practitioners,Company-affiliated facilities must ensure that each physician or allied health practitioner is not listed as excluded on the Office of Inspector General (OIG) Sanction Report or General Service Administration’s (GSA) List.

Furthermore, facilities can encounter two types of physicians or allied health practitioners who order tests or services:

  • Those who have been privileged by the facility to order specific tests or procedures; or
  • Those who have not been privileged by the facility to order specific tests or procedures.

The following guidelines address the initial implementation and daily process each Company-affiliated facility must follow to ensure tests and services are ordered by qualified individuals who are ineligible and licensed persons.

Initial Implementation

Establish Market Representatives

Implementation of QM.002 requires the determination of who within the market will coordinate the implementation and daily processes associated with this policy and how Medical Staff Office personnel will be involved. A core team should be established for each Clinical Patient Care System (CPCS) market to be involved in reviewing the MIS Provider Dictionary. This team should include representation from Business Office, Health Information Management, Medical Staff Office, Admitting/Registration, Information Systems, and ancillary areas.

MIS Provider Dictionary

A complete, accurate and up-to-date MIS Provider Dictionary is the key component for successful implementation of this policy.

The following initial steps will be taken to verify physicians and/or allied health practitioners in the existing MIS Provider dictionary.

  1. Ensure all members of the core team are involved in reviewing the MIS Provider Dictionary.
  1. Create an action plan and assign responsible team members for performing the review of the entries in the dictionary.
  1. Review existing entries in the MIS Provider Dictionary by performing the following minimum steps:

a.Run the MIS provider listing which lists entries in the dictionary.