Health Plan (7.4) 7.4
P-CR 10 - Consumer Safety Credentialing Investigation
This extremely important standard requires that, if the credentialing process reveals information that indicates factors that may impact the quality of care or service provided to consumers, the organization conducts additional review and investigation of that provider.
Your organization's policy and procedure on this issue no doubt spells out the circumstances that should trigger further investigation. Such circumstances are likely to include information about malpractice litigation, missing information, or inconsistent information. What your policy probably provides for is closer examination of such files by a senior clinical staff person. It's also very likely that your policy and procedure requires that such files be discussed in detail by the credentialing committee.
It will be particularly important that you follow the policy and procedure regarding how you document any such follow-up activities. Documentation should be clear and detailed regarding what was done, who did it, and when the activity was conducted.
Your policy and procedure should be quite clear in providing guidance to credentialing staff members as to what should trigger further investigation. Your policy also should provide clear guidance as to who should conduct investigations, and whether senior clinical personnel should be involved. Finally, your policy should articulate explicitly how such a file should be presented to the credentialing committee.
During the desktop review process, you should submit not only your credentialing plan, but some sort of description of the roles of various staff members, clinical or otherwise, in handling the identification and investigation of "problem files". This documentation can come in the form of the credentialing plan, policies and procedures, or job descriptions.
The URAC reviewer will conduct interviews with the senior clinical staff person and members of the credentialing staff.
During the on-site review, the standard will be verified through a review of credentialing files in which such investigations took place.