How to Optimize the Privileging Process for APPs

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Healthcare provider privileging is the process in which hospitals and clinics educate, train, and document the skills and procedures of all medical staff. Traditionally this process has been considered a cumbersome, administrative burden, but more recently has become an opportunity. Institutions who optimize this process can increase revenue, for example by utilizing APPs (Advanced Practice Providers) efficiently when a pandemic hits and more providers are needed in ICUs and Emergency Departments. CNS, NP, PA, CRNA and other APRN Leaders who work to create and optimize the privileging process for APP can increase reimbursement, redeploy APPs when needed, and fully utilize APPs in their roles.

How to Assess and Build an APP Privileging Process at Your Organization

Medical Staff privileging is determined by the Medical Staff bylaws, rules, and regulations, CMS, Joint Commission or other certifying bodies, and the state scope of practice for NPs and PAs. Some states, such as Georgia, require a state run organization to grant APP privileges. This is very laborious and requires members of the state committee to understand the scope of practice for APPs. Most states, however, leave the process up to individual organizations and their respective certifying bodies. Under the APP Leadership of Diana Vance, Summa Health, an Ohio-based hospital system, has built a reliable system for educating, training, and evaluating APP skills to justify granting privileges on an annual basis. Diana worked with others to create clinical competency pathways to ensure not only that APPs are consistently and properly oriented, but also that they meet specific competencies within specialties.  When Assessing Privileging at Your Organization, Here are Some Questions to Ask:

• Are there job descriptions, collaborative agreements, standardized procedures, and protocols for the role?
• What is the state scope of practice laws for NPs and PAs?
• Are APPs credentialed and privileged by Medical Staff or the state?
• Is there alignment between the regulations of a certifying body (such as Joint Commission), CMS, state laws and regulations, hospital bylaws, rules, and regulations?
• Does the required supervisory level of the physician include general supervision, direct supervision, or indirect supervision?
• Do the bylaws, policies, rules and regulations need to be changed to align with state scope of practice, Joint Commission, and CMS?
• Do the APP leaders need to be included as voting members of Medical Staff Committees?
• Does the APP leader meet with the credentialing team to discuss the needs of the credentialing department and to find opportunities to decrease the time to full credentialing?
• Does the APP leader need to review all collaborating agreements, billing processes, and supervisory processes for compliance?

If there are areas of misalignment, your hospital could be at risk for negligence in credentialing. The cost of non-compliance with Stark Law and Anti-Kickback statutes can be $10 to 50 million dollars in fines or more according to a 2017 article in Compliance Today by Charles Oppenheim, Esq. and Amy Joseph, Esq. To Assess Stark Law Risks, Here are Some Questions to Ask:

• Who employs the APPs and physicians? For example, does the hospital employ the physicians and the APPs, or only the APPs? Does a medical group employ both the APPs and physicians?
• Who saw the patient and who did the initial appointment?
• Where was the supervising physician when the APP provided services?
• Can you add a billing and servicing provider distinction within the EMR to provide a mechanism for data analysis to gauge compliance?

Credentialing and privileging APPs in an accurate and timely manner impacts Revenue

According to the Greeley Company, in an Becker's Hospital Review Article, not credentialing in a timely fashion for a primary care physician can amount to a lost revenue of $30,000 per month. APPs bring in the same, or slightly less revenue than physician colleagues, at a lower cost to the institution. Inpatient providers, who also need to be privileged at the hospital and who can produce higher revenue, can have a much bigger impact on the bottom line. Privileging appropriately not only impacts the quality of care, but revenue for the employer.

Create an OPPE and FPPE Process to Evaluate Privileging Process and Competencies for APPs

According to the Joint Commission, Ongoing Professional Performance Evaluation (OPPE) is “a document summary of ongoing data collected for the purpose of assessing a practitioner’s clinical competence and professional behavior. OPPE allows organizations to identify professional practice trends that impact the quality and safety of patient care.” A Focused Professional Practice Evaluation (FPPE) is “a process whereby the organization evaluates the privilege-specific competence of the practitioner who does not have documented evidence of competently performing the requested privilege at the organization. This process may also be used when a question arises regarding a currently privileged practitioner's ability to provide safe, high-quality patient care.” Providers need to be evaluated not only on the number of encounters, but the quality of care for those encounters. In her JNP article, titled Ongoing Professional Performance Evaluation: Advanced Practice Registered Nurse Practice Competency Assessment, Sharon L. Holley, DNP, CNM, defines the OPPE as a “documented summary of ongoing data collection and tracking for the purpose of assessing a practitioner's clinical competence and professional behavior.” Questions to Ask:

• Does the APP leader need to meet with the credentialing department to help develop OPPE and FPPE processes?
• Do the OPPE/FPPE process and competency reports align with privileges granted?
• Are there APRN-specific clinical domains?
• Are there APP-specific clinical competencies for each specialty?
• Are there clear and measurable metrics, such as in the emergency department, how many patients are left unseen? How many patients returned to the emergency department?
• Are there set behavioral standards?
• Can you use Medical Training standards and competencies as a starting place for APPs?

What's Your Next Step to Optimize the Privileging Process for APPs?

Building relationships and working collaboratively with finance, data, legal, credentialing, compliance, and leadership is an effective way for APP leaders to move initiatives forward, support the role of the APP, and advance the organization. The next step for many APP Leaders to optimize privileging at their institution is to:

• Read the bylaws of your organization, state scope of practice, and meet with the credentialing and privileging departments to understand processes. Mapping out the current process within your organization and state is the first step towards improving that process.
• Work with the organization and the credentialing department to consider merging credentialing with payor enrollment. This can decrease the cost of duplicated processes and decrease processing time to increase revenue.  
• Work closely with staff in data and finance to build an APP dashboard to measure performance and efficiency.
• Add dashboard features such as educational, skills labs, simulation, and document tracking for privileging and OPPE.

Helping your organization achieve compliance, reduce risk, and create accurate, measurable goals is a big task.

This article was originally published on Melnic by Jill Gilliland. Melnic was recently acquired by DirectShifts. Click here to sign up on DirectShifts.