Credentialing Standards   /   July 2018

NCQA Requirements, Part 5: Ongoing Monitoring

NCQA Requirements, Part 5: Ongoing Monitoring

In this series, we break down what you need to know about credentialing, re-credentialing and delegated credentialing. In prior posts, we covered organizational requirements (CR 1), credentialing committees (CR 2), the establishment of credentialing requirements (CR 3) and information that the credentialing committee needs to review (CR 4 – 8).

Here we will cover what happens between cycles of credentialing or CR 9, Ongoing Monitoring.

NCQA requires organizations to “conduct ongoing monitoring of practitioner sanctions, complaints and quality issues” and to “take appropriate action when issues are identified.”

Why is ongoing monitoring important?

It is your organization’s responsibility to know the up-to-date status of all your providers, even between credentialing cycles. After you have credentialed providers and before you credential them again, it is important to monitor your providers because patient safety, client care and your reputation are on the line. The three-year cycle for payers and the two-year cycle for provider organizations is a long time; events that negatively reflect on providers and facilities can occur during these time periods. One of our clients described the burden this way: “The last thing I want is for a patient to Google the doctor’s name, and they pull up the sanctions before I’m even aware of them.” We live in the information age and credentialing standards reflect that.

Monitoring for red flags

Federal and State Sanctions

It’s important to know the background of the doctors you are recommending to your patients. Sanctions are one way to know more about your providers. A sanction is considered any penalty, punitive or disciplinary action imposed on providers when they are found in violation of a law or regulation governing the practice of medicine.

How to Monitor Sanctions:

The Office of the Inspector General (OIG), System of Award Management (SAM) and General Services Administration (GSA) keep record of sanctions and publish a list of entities including providers and facilities on a monthly basis. To access them you can Download the file here or search here.

Download the file every month, open the document in your favorite spreadsheet tool and search for the names of each of your providers or search online one at a time.

CredSimple Pro Tip: CredSimple will do this for you and automatically alert you if any of your providers’ names appear.

Between cycles, licensure can change for any practitioner. Expiration as well as adverse events are possible. As a result, licensure needs to be monitored and typically one can accomplish this via the National Practitioner Data Bank, particularly via the continuous query (CQ) option. It is recommended to use the CQ option given any red flag surrounding a license issue will immediately result in a push notification of the alert.

National Practitioner Data Bank
National Practitioner Data Bank (NPDB) is a federally supported and mandated organization that serves as a clearinghouse to collect adverse action and malpractice data reported on health care practitioners. Key data used in ongoing monitoring includes malpractice claims/awards, loss of license or exclusion from participation in Medicare or Medicaid.

NPDB reports data via query or continuous query options. The latter automatically notifies the client and healthcare organization of any red flags and alerts. Examples of data that the NPDB reports includes:

  • Medical malpractice payments
  • Any adverse licensure actions or loss of license
  • Adverse clinical privileging actions
  • Adverse professional society membership actions
  • Any negative action or finding by a State licensing or certification authority
  • Private accreditation organization negative actions or findings against a health care practitioner or entity
  • Any negative action or finding by a Federal or State licensing and certification agency that is publicly available information
  • Civil judgments or criminal convictions that are healthcare-related
    Exclusions from Federal or State health care programs
  • Other adjudicated actions or decisions (formal or official actions, involving a due process mechanism and based on acts or omissions that affect or could affect the payment, provision, or delivery of a healthcare item or service)

Taking appropriate action

It is absolutely necessary to have an internal standard operating procedure to respond to any provider alerts during ongoing monitoring. Credentialing staff and committee should be informed and ready to take action when a situation arises.

If the appropriate response includes removing a practitioner from a roster, the practitioner needs to be immediately notified. He or she has the right to file an appeal for review. In addition, the practitioner can inquire about the reason for the action taken by the health plan or organization. It is crucial to have the steps and actions clearly documented in the credentialing bylaws and standard operating procedures, so that an organization is prepared to take action if something is arises.

Knowing the quality and consistency of your provider network requires good practices for the creation, collection and maintenance of your provider data. Ongoing monitoring for sanctions, disciplinary actions, and licensure are good initial steps to provider data maintenance. If you need help to conduct a provider data quality audit contact us today.

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