Credentialing and Contracting Insights at BCBSOK - PowerPoint Presentation

1. Credentialing and Contracting Insights at BCBSOKDoug Stewart, DO, MPHMedical DirectorSeptember 2021

2. The APRN Consensus ModelL.A.C.E. – licensing, accreditation, certification, and educationPopulation focus and area of emphasisIndependent practice statusCollaborative practiceHistoric incremental public policy changes without corresponding operational changes by stakeholders in OKContinued evolution of model and implementation2

3. BCBSOK and APRN countsCNP3,322 in our credentialing database649 reviewed in Committee for scope of practice since early 2019CNS178 in our database6 reviewed in Committee since early 2019 for scope concernsCRNA1,166 in our databaseScope of practice concerns not identifiedCNM73 in our databaseScope of practice concerns not identified3

4. Health Insurance Plan perspectiveContractual agreements are made with clinicians to pay for in-network services to membersCredentials must be approved as a prerequisite to engage in a contractual relationship with the PlanApproval of specific credentials submitted by the clinician corresponds with the expected scope of servicesSome credentialing decisions are delegated to organizations with capacity to manage this function. Subject to auditsSome clinician contracts are currently included in hospital-based contractsHospital credentialing differs in detail of additional focus on procedures, but otherwise similarIndependent practitioners versus dependent practitioners4

5. BCBSOK processCredentialing CommitteeMeets twice per monthIncludes a diverse group of external voting clinicians along with a few internal voting members. Includes one APRN-CNPConsiders all initial and recredentialing applications (every 3 years)Peer Review CommitteesTwo Committees, each with unique set of external, voting clinicians. Includes two APRN-CNPs and one APRN-CNSEach Committee meets alternate monthsLevel 1 appeal is a reconsideration of documents plus additional submitted information in the form of new documentsLevel 2, and final, appeal is a reconsideration of all previously submitted documents, any new documents, AND a synchronous communication with the Committee5

6. Important documentsCredentials √6LicenseDegree(s)Certification(s) – only APRegistrations (CDS)Some experience consideredSome academic appointments consideredNOT credentials ≠Continuing educationPreceptorship - not accreditedRN certification or experienceProfessional membershipSubscription to journals or Up To DateLetters of recommendationMission tripsApproval of credentials from other organizations

7. Area of emphasis:Acute care versus Primary careScope is not specific to a clinical setting but is determined by the needs of the patient. (Neonatal NP, WH-NP, and PMH-NP)A need for, and the provision of, acute care is best considered as a physiologically unstable patient – no matter the settingWhere will a clinician encounter physiologically unstable patients?Certain clinical procedures are incorporated into the training of acute care emphasis CNPs and CNSs who graduate from accredited programsCertifications not currently recognized for licensure requirement in OK, but recognized by our Committees: emergency, oncology, urology, cardiovascular diseasePre-APRN Consensus Model credentials7

8. Approach to an appealCommunicationImperative to not delegate communication to othersImportance of accurate contact informationUse focus on actual credentials – see previous listCredentialing staff at many large groups are familiar with process and approachFollow the instructions in the letters thoroughly and preciselyConsider the audienceCollaborative and/or sponsoring physicians are not helpfulYears of APRN experience are considered and factor into decisions8

9. Work gaps and re-entry to practiceNot addressed by OK Board of Nursing (yet) but has been addressed by both physician licensing boards in OKComplete absence of clinical work versus primary care work gapNeed to use common sense and professional judgment“Structured” process to prepare for re-entry into practice9

10. Common credentialing issues referred to CommitteeDisclosures and omissionsLicense board actionsEducation / training probation, suspension, termination, etc.Malpractice settlements and payments above a thresholdInadequate malpractice coverage, inadequate hospital coverage, absence of non-CDS or CDS Rx authorityScope of practice outside the clinician’s education and trainingTime gap in work historyInability to primary source verify a credential10* This is not a comprehensive list of issues or criteria