The medical staff services office keeps the wheels turning in your hospital or health system. And while its personnel—medical staff professionals (MSPs), payer enrollment specialists, and credentialing professionals—are vital, they may go unnoticed because their work occurs behind the scenes. When they're at their best, the organized medical staff is better positioned to deliver excellent patient care and contribute to overall hospital and provider success. As a result, it’s essential for anyone in healthcare to understand the importance of the medical staff office as it pertains to the healthcare business.
A bridge between providers and administrators
Healthcare governance requires the C-suite to work in concert with healthcare providers and staff to ensure that policies and procedures solve real-world problems, all while keeping a uniform and human-centered approach to patient care. This oversight is part of the full spectrum of operations, checks, and balances called healthcare governance, risk management, and compliance (GRC). Often tucked into the administrative wing of the hospital—yet still accessible to all providers—the medical staff office is a hive of activity for the intersection of clinical and administrative functions.
The essential medical staff office
The administrative work behind making providers available for every patient must be seamless to the patient and the provider. This is where the medical staff office comes in, helping the organization to ensure that clinicians with the right credentials are vetted and available to care for patients. As a result, the office’s work has a tangible impact on patients, healthcare providers, and staff.
Of the various logistical and operational responsibilities that the medical staff office handles day-to-day, provider data management is perhaps the most important. In carrying out this function, the medical staff office collects, analyzes, and maintains providers’ lifecycle data to complete multiple steps that must occur before any provider is allowed to provide patient care or services.
In most hospitals, provider data management encompasses the following activities:
- Onboarding: This step often includes contracting, which may include compensation, bonuses, relocation assistance, tuition reimbursement, and more.
- Primary source verification/credentialing: A provider’s credentials are the data related to their education, training, licensure, board certification, references, insurance, and more. This step entails tracking down and often communicating directly with a representative of the “primary” source, or issuer of the data or document, to verify its authenticity. However, technology now automates some verifications.
- Privileging: After the medical staff office gathers and verifies a provider’s credentials, the clinical leaders use those credentials to determine the privileges—the specific procedures and services—it will delineate to the provider in a given facility or network site. (Privileges may differ between sites, even within the same healthcare system.)
- Provider enrollment: Enrolling providers with government (e.g., Medicare and Medicaid) and/or commercial (e.g., Cigna, UnitedHealthcare) health plans is a necessary step before providers deliver care and services to hospital patients, so that the hospital can bill for services.
- Ongoing monitoring of provider performance: Often, the medical staff office works in conjunction with the quality department to gather and report on providers’ performance data over time for accreditation, reimbursement, and providers’ personal improvement purposes.
In addition, the medical staff office handles wide-ranging tasks generally related to provider relations and management, including:
- Committee management (e.g., credentialing, medical executive, peer review, and departmental meetings)
- Coordination and/or tracking of providers’ continuing medical education activity
- Accreditation and regulatory compliance activities related to the medical staff
- Development and/or maintenance of medical staff governance documents (e.g., bylaws, policies, procedures)
What would a day without the medical staff office look like?
With the medical staff office’s vital and wide-ranging roles in mind, we take a closer look at what a day without it would look like, and address how to optimize the efficiency of your medical staff office using innovative provider data management.
Healthcare would be risky business
It’s often said that one of the highest risk procedures in any hospital is not a medical procedure, but the credentialing process. And rightly so. There are too many cases to count in which a provider intentionally or unintentionally harmed one or more patients due to negligence or criminal activity. The most famous criminal case is that of Michael Swango. A physician and serial killer, he used his access to hospitalized patients—and a stunning lack of safeguards and information-sharing among healthcare organizations at the time (1981–1997)—to kill approximately 60 people.
Red flags of problems with providers’ backgrounds or abilities can pop up in background checks, on enrollment applications, in job time frames, and in malpractice claims. Most provider applications for hospital privileges or medical staff membership don’t raise red flags, but it’s the medical staff office that delves into any questionable items found by using technology.
Credentialing done well means that your health system hires or affiliates with only those providers who are who they say they are—and who are qualified and currently competent to provide care and services to patients.
Risk management and the achievement of patient safety would be impossible without the medical staff office’s personnel to pore over the large amounts of data they quickly gather, review, and process to investigate any discrepancies.
Hospitals could not meet revenue goals
Your staff is shrinking, the workload is growing and your healthcare organization has acquired a practice with 250 new providers. How do you get them onboarded, enrolled with payers, and credentialed by the end of the fiscal year? The medical staff office is responsible for:
- Updating or adding practitioners’ data into commercial (private) and/or government payer networks to ensure proper reimbursement
- Verifying the credentialing criteria for practitioners
- Following up with providers and payers to obtain missing or inaccurate data
The medical staff office also un-enrolls providers from payer networks to maintain accuracy and must understand which types of providers to enroll to keep organizations from running afoul of legal issues (think: fraud). In addition, there are extensive negative consequences if your hospital bills for a procedure or service that a provider isn’t privileged for and/or isn’t currently competent to perform. Preventing such scenarios requires integrated governance over the often-disparate processes of credentialing/privileging, quality and performance monitoring, and revenue cycle.
Credentialing and enrollment are time-consuming tasks, considering that the average practitioner may enroll into 6-10 different plans, all with varying data requirements and rules. As a result, many healthcare organizations outsource enrollment rather than risk having costly outstanding claims.
The medical staff office is essential in the revenue cycle process and thus is critical to your organization’s bottom line. Ensuring that its personnel have access to the right technology is a rare investment in healthcare, because it enables revenue recovery in weeks, not years, which is the case with other investments.
Accreditation and value-based care would be impossible
In many hospitals, the medical staff office works closely with the quality department to gather and report on providers’ performance data over time. This process is crucial for quality and safety, of course. But now, value-based healthcare is replacing traditional fee-for-service models.
Providers, including hospitals and physicians, are paid based on patients’ health outcomes. How well providers perform on various measures compared to other hospitals’ performance and how much the providers improve their performance on each measure (compared to their performance during a baseline period) affect the amount the hospital will be reimbursed.
Without the medical staff office, the gaps between privileging, quality (ongoing professional practice evaluation), and revenue functions could lead to compliance and reimbursement trouble.
Unhappy providers would abound
Seeking to attract and keep providers in a competitive environment? Then accreditation, reimbursement, and safety/quality shouldn’t be the only concerns. Your providers are internal customers. Their satisfaction with their contracting or employment process initially—and their happiness in practicing within the hospital or health system long term—can foster commitment to you over the competition. Physician shortages in many regions are exacerbating the problem.
The pressure is intense on today’s providers to balance business interests and patient care. They must use electronic health records, increase patient volume, improve quality, learn the business of medicine, and yet still practice self care to avoid fatigue and burnout.
Your health system’s best ally in supporting them is your medical staff office. Why? It’s integral in physician-hospital relations because it has the power to avoid making administration a burden and to let providers do what they do best: care for patients.
Far-reaching, crucial provider data management
There’s no dark corner of healthcare untouched by the need to collect and manage large volumes of accurate provider data to improve quality, safety, and reimbursement. In fact, the essential provider and health plan data the medical staff office handles feeds an increasing number of internal and external uses, including the following:
- Patients use it to select caregivers and employers use it to select a health network
- States and other bodies use it for licensing decisions
- Hospital and healthcare administrators parse it for patterns to make decisions about business processes and patient care
- Regulators require it to ensure compliance on both the hospital and payer/health plan sides of healthcare
Without the medical staff office and the resources its staff relies on to manage provider data, hospital care truly would be gridlocked. Ensure that your medical staff office has the technology and tools it needs to succeed in the digital age.