Verification Practices for the Non-Physician

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Authors: Donna Goestenkors, CPMSM and Mary Jo Sexton-Tosh, MHA – Team Med Global Healthcare Consulting in collaboration with the IntelliSoft sponsored “Doctor FBI Series, “Verification Practices for the Non-Physician Practitioner.”

It is common today to pick up a healthcare publication and see an article related to the increase in use of non-physician practitioners in today’s healthcare environment. We are all familiar with the fact the Affordable Care Act brought with it millions of additional covered lives that was greater than the number of practicing physicians could effectively manage. As a result, it wasn’t long before physicians began to experience burnout, many of whom retired or moved into other less stressful areas of healthcare outside of primary care.

In order to effectively care for the patient population, the use of non-physicians soon became prevalent; however, this shift in practitioners brought with it special challenges for the MSP, one of which is the establishment of effective verification elements via the most current web sources to conduct primary source verification to establish competency for the non-physician group.

The following top 25 elements were shared during the webinar:

  • Application
  • Education
  • Certification
  • Licensure
  • Sanctions Against Licensure
  • Professional Liability/Malpractice Coverage
  • Malpractice History
  • Work History
  • Scope/Collaborative Agreement
  • Current Clinical Compliance
  • Medicare/Medicaid Sanctions
  • Ongoing Monitoring of Sanctions & Disciplinary Actions
  • DEA/State Controlled Substance (as appropriate)
  • Ability to Perform
  • Membership
  • Clinical Privilege History
  • National Practitioner Data Bank (NPDB)
  • Criminal Background Check
  • Identity
  • Release & Authorization
  • Peer References
  • CME Documentation
  • Case Logs
  • Notification of Decision to Practitioner
  • Onboarding

The key to success for the verification process, as identified by MSPs, is to have a firm understanding of the scope of practice of each non-physician specialty, as well as a solid understanding of the standards put forth by THC, URAC, CMS and NCQA, governing the practice of non-physician providers. Additionally, the MSP must also understand the organizational policies in place to determine the practice requirements for their specific company.

Clinical competence of the non-physician must be determined by using the scope of practice for their particular specialty. Similar to the process utilized by MSPs to determine the competency of a physician, the verification of education, certification, liability insurance and history, licensure, work history and sanctions all apply. Verification of current clinical competence is managed through the primary source verification process of the 25 verification elements and the peer reference process, and by a solid understanding of the scope of practice, we can incorporate and utilize the six general competencies (i.e. patient care, medical/clinical knowledge, practice-based learning, communication skills, professionalism and systems-based practice).

By incorporating the non-physician scope and competence into the overall credentialing process and systems, the MSP will also be able to measure non-physician performance effectively and efficiently via the quality management process, as we will explore in the next Doctor FBI webinar. The importance of the MSP incorporating the non-physician scope and competence into the overall credentialing process and systems cannot be overstated and is paramount in solidifying the non-physician provider into the healthcare team.

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