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Five Key Takeaways for NP and PA Leaders: Credentialing and Privileging

Posted on September 19, 2019   |   by   |   Advanced Practice Provider, Credentialing, Employers, Job Seekers

NPs and PAs can advocate for full practice authority by understanding credentialing and privileging in their organizations. Learn tips from exceptional Advanced Practice Leaders and a Credentialing Manager to help you bring positive change to your organization.

I recently caught up with Courtney Robinson, MSN APRN CNS CPNP-AC, Director of Advanced Practice Providers; Sara Watson, MHA, MBA, CPMSM, Manager Medical Staff Services from Children’s Hospital and Medical Center- Omaha and Beth Paton, DNP, PNP-AC/PC from Le Bonheur Children’s Hospital in Memphis. These dynamic women are experts in the field regarding credentialing, Medical Staff services and compliance. 

Together, we developed the following takeaways for every Advanced Practice Leader who wants to advocate for full practice authority.

1. Know The Difference Between Credentialing and Privileging

Healthcare organizations are responsible for validating the competency of their Nurse Practitioners and Physician Assistants through credentialing and privileging. 

In a  useful guide to Credentialing and Privileging by the MedPro Group, Credentialing is defined as the process by which a healthcare organization assesses and confirms the qualifications of a practitioner, and ensures that individuals who are providing care are qualified to do so. Privileging is defined as the process of authorizing a licensed or certified healthcare practitioner’s specific scope of patient care services. This is assessed in conjunction with credentialing, which includes the evaluation of an individual’s clinical qualifications and/or performance. 

These processes are closely tied to reimbursement, accreditation standards, state and federal laws. Failure to adhere to solid credentialing and privileging procedures might result in a costly negligent credentialing claim against an organization. As an APP Leader, your role is to educate and work with your organization’s credentialing department to be in compliance with state and federal laws regarding credentialing.  Having a detailed and consistent credentialing and privileging process is imperative. 

2. Assess Credentialing and Privileging at Your Organization

Medical Staff credentialing and 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. You can start with a gap analysis to understand what should be in place and what is the current state of your organization. 

Questions to Ask:

  • Are there job descriptions, collaborative agreements, standardized procedures, protocols, etc. for your role?
  • What are the state scope of practice laws for NPs and PAs?
  • Are APPs credentialed and privileged by Medical Staff
  • 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, and personal 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 credentialing to discuss the needs of the credentialing department and to find opportunities to decrease the credentialing time?
  • 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. 

3. Understand that Stark law and billing risks are closely tied to employment and credentialing processes

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:

“As hospitals continue to identify ways to increase the quality of care and improve patient experience, while also reducing cost, employment of NPs and PAs can be an effective tool to assist with patient care management issues. However, in doing so, hospitals should take care not to violate the Stark Law by providing impermissible financial benefits to physicians. In particular, potential compliance issues might arise if a physician bills for E/M services shared with NPs and PAs employed by the hospital, if the physician is viewed as impermissibly billing for services performed by the NP, and thus the NP’s services are viewed as remuneration from the hospital to the physician, in violation of the Stark Law.”

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? 

4. Having A Risk Mitigation Plan is a Key to Compliance

Risk mitigation plans help to ensure the organization complies with laws and certifying bodies.  As an APP leader, you can create an SBAR (Situation-Background-Assessment-Recommendation) based on the results of your gap analysis between the desired state and current state of credentialing, privileging, and billing practices. Meet with your medical directors, and heads of your legal, finance and compliance departments to build aligned processes for standardization of APP employment, credentialing, and privileging practices.  These practices are uniquely designed for nurse practitioners and physician assistants to comply with laws, regulations, and certifying bodies.

5. Understand How a Hospital’s OPPE and FPPE Processes Can Create Challenges for NPs and PAs

According to Joint Commission.org, an 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.”

Organizations are challenged to set up dashboards to provide transparency into productivity, quality, and behavior metrics and benchmarks for nurse practitioner and physician assistants. The biggest obstacle can be the lack of data.  NPs and PAs regularly document patient encounters and outcomes in the EMR but many times it is only the physician who is identified as the provider in the records.  

Many organizations set up a billing and service provider field in the EMR to provide quality data on the APPs.When building a dashboard, a critical component of is the ability to validate that the metrics are specific and measurable. APPs working in the same unit but in different roles most likely will need different metrics if the complexity and acuity of the patients vary. Behavioral competency can be included in a dashboard and standardized across the organization. It is important to include non-clinical contributions to research, quality projects, committees, or education in the dashboard. Dashboards that include information on the quantity metrics can allow the organization to create an incentive-based bonus structure. 

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, for how many patients are left unseen? How many patients returned to the emergency department?
  • Are there set behavioral standards? 

Bonus: How One Hospital Reduced Credentialing Time from 120 Days to 45 Days

Children’s Hospital and Medical Center-Omaha, reduced credentialing time by 62.5%. The Credentialing Department worked closely with APP leaders and HR to streamline processes. 

They approached the challenge by taking several approaches:

  • APP leadership started developing relationships with the Medical Staff office to understand their needs and understand how to support one another.
  • Set a meeting with the CMO to gain approval for APP leadership on the Medical Executive Committee, explaining the benefits of representation such as decreased credentialing time, improved APP credentialing processes, and increased APP expertise.  
  • APP leadership coordinated a meeting between Medical Staff leadership and the hiring team in human resources. The collaboration resulted in a workflow to notify credentialing when a new APP is hired in order to streamline communication.
  • The establishment of a timeline for processes with dependencies to help candidates who already hold state licenses. Under this process, the credentialing department contacts the new hire by phone and email to provide information regarding the details of the credentialing process. This step also establishes a relationship between the new hire and the credentialing specialist.  The new hire needs to understand their responsibility in the process. 
  • A set timeline for the process by the credentialing specialist. For example, if there is no response from references within 5-7 days, the specialist will call the new hire to ask for their assistance with contacting the reference. 
  • The Manager of Medical Staff Services now manages the timing of the credentialing package with the Credentials Committee, the Medical Executive Committee, and Executive Board meeting dates, making the new hire aware of the deadlines as well.

What’s Your Next Step to Improve Credentialing and Privileging at Your Organization?

The next step for many APP leaders is to work with the organization and the credentialing department to consider merging credentialing with payor enrollment. This can decrease the cost of duplication of processes and decrease processing time to increase revenue.  An effective step may also be to work closely with staff in data and finance to build an APP dashboard to measure performance and efficiency. As a next step, consider adding dashboard features like document tracking for recredentialing and FPPE plans as needed. 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.


Helping your organization achieve compliance, reduce risk, create accurate measurable goals, is a big task.  Melnic is here to help you connect with others in your fields for support and to share ideas to empower you as you work to build and grow the role of the APP in your organization. 

Here are some resources to help you in your leadership journey.

Please contact Jill Gilliland, President of Melnic, to help you on your way: 

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