A Texas-based pathologist resigned after learning his employer charged his insurance company nearly $11,000 for a COVID-19 antibody test. Zachary Sussman, MD, said he decided to use one of the freestanding ERs owned by Physician Premier ER, so he could witness the patient experience offered by his company.

Once the medical staff and governing board grant a practitioner clinical privileges, the medical staff is then responsible for ensuring that the practitioner maintains current clinical competence by monitoring and reviewing the quality of care provided by the practitioner and the practitioner’s overall performance. To monitor competence on an ongoing basis, organizations must develop systems to collect and assess performance data to measure the quality of care their practitioners deliver and ensure that the organization permits practitioners to maintain only those privileges they are competent to perform.

Mary, a medical staff quality coordinator, has been charged with gathering activity information for all practitioners for ongoing professional practice evaluation (OPPE). Mary requests the data from several departments, including admitting, information systems, medical records, pharmacy, and financial services. When comparing the data submitted from each of the departments, she quickly realizes that there is a discrepancy. She presents the data to the medical staff leaders, and they identify that there must be errors in the way data are being attributed to practitioners. They now face the challenge of identifying at which step in the process the data are inaccurately attributed.

Any MSP will tell you that they wear many hats. Frequently, MSPs have their hands in a little bit of everything related to credentialing, contracting, provider enrollment, and the medical staff itself. Deborah Ormay, CPCS, CPMSM, a writer and speaker with more than 30 years of managed care credentialing experience, discusses what separates credentialing, contracting, and provider enrollment, and more importantly, what unites the people who perform these key functions.

The operational process of credentialing a practitioner to participate in a health plan’s network has some similarities to a hospital’s credentialing processes; however, there are also important distinctions. The following table highlights some of the key differences between health plan credentialing and hospital credentialing, using NCQA and Joint Commission standards, respectively.