Privileging & Evaluating Nonphysician Providers
Amid the growing physician shortage in the U.S., healthcare organizations continue to rely on nonphysician providers— including advanced practice professionals (APPs)—to fill the gap. APPs boost productivity, patient satisfaction, and revenue through cost savings and patient acquisition. As a result, they’re proving to be a key to value-based care success, which hinges on advancing quality, increasing patient access, and lowering costs at the point of care.
Licensed APPs can complement, supplement, or supplant physicians, surgeons, dentists, and others for certain services, depending on state laws.
This handbook provides all the guidance you need to ensure that your APP policies and procedures are as stringent, compliant, and up to date as those used for your physicians.
Who are APPs?
Historically, all nonphysician providers worked under the supervision of physicians. Increasingly, however, their practice scopes are expanding—and some have gained practice independence. Today, the term APP represents multiple clinical disciplines, titles, and levels of practice. The term generally does not cover non-licensed care providers.
To better understand the categories of hospital practitioners, look to the clinical privileging function, which holds the key. Privileges are the specialty- and site-specific procedures and services a licensed practitioner is authorized to perform in a facility.
Joint Commission standards
While no provider works absent any oversight (e.g., laws, regulations, and policies), physicians, dentists, podiatrists, and clinical psychologists are categorized as licensed independent practitioners. According to The Joint Commission (TJC), it’s up to each organization to define LIPs. However, defining them is highly dependent on the licensure laws in each state. TJC also requires privileging for physician assistants (PAs) and advanced practice registered nurses (APRNs)—the latter defined by most states’ nursing boards as inclusive of:
- Certified nurse midwives
- Clinical nurse specialists
- Certified registered nurse anesthetists
- Nurse practitioners (NP)
CMS regulations
In 2012, The Centers for Medicare & Medicaid Services (CMS) expanded its definition of the hospital medical staff. While CMS didn’t define APP, it gave hospitals the flexibility to include nonphysicians as eligible candidates for the medical staff, with hospital privileges to practice in accordance with state law.
CMS requires a healthcare organization’s governing body to ensure that all practitioners who provide “a medical level of care and/or conduct surgical procedures in the hospital are individually evaluated by its medical staff and that those practitioners possess current qualifications and demonstrated competencies for the privileges granted.” The specific privileges available to each category of provider must be clearly defined. In addition to PAs and APRNs, additional practitioners may be providing “a medical level of care” in your organization, thus requiring privileges. Note that the decision about whether to privilege an APP should rest on the complexity of services they provide, not on their title.
In summary, the guidelines for defining who is an APP—and what services they can provide—come from:
- State licensure laws
- TJC (or other hospital accrediting body; for example Det Norske Veritas)
- CMS
- The healthcare organization itself; typically the organized medical staff
Handle APP scope expansion carefully
As more states expand APPs’ practices, it’s critical to monitor your policies to avoid violating licensure laws and compliance standards, or worse—enabling patient harm. Let the following tips serve as a guide for thoughtful enterprise-wide policies when expanding APPs’ roles:
- Define the roles categorized as APPs.
- Investigate whether your organization has a mechanism to address the growing trend of scope expansion:
- Is training up allowed and by whom? (E.g., supervising physician, sponsor, other)
- Does the governing body and organized medical staff have a formal, documented position on training up?
- Does the organization’s insurance carrier have a formal, documented training-up policy?
- What do the bylaws, policies, and procedures state about patient consent in circumstances where APPs are in training for expanding their scopes?
- Address whether there are APP core privileges and special procedures that require additional training, education, and experience, especially if your organization employs or contracts with specialty and subspecialty NPs or PAs.
- Specify whether APPs can be members of the medical staff, and identify those eligible.
- Specify whether APPs can hold office and/or serve on committees, and identify those eligible.
Use APPs to grow and compete
The COVID-19 pandemic exacerbated the physician shortage and displayed the negative effects of inadequate staffing and retention plans, especially for nursing staff. But even before the pandemic hit in 2020, data confirmed that the demand for physicians would continue to grow faster than the supply. Consider that the nation’s aging population requires more caregivers, just as one-third of all active doctors prepare to retire. Many more are leaving the profession due to burnout and other factors.
APPs can’t replace physicians’ extensive education, training, and experience for certain services and procedures. But they can relieve some of the weight on physicians’ shoulders when they’re qualified, properly trained, privileged, and monitored to work within their practice scopes.
A strategy that incorporates more APPs as significant contributors to team-based care, for example, can give health systems a competitive edge. This is especially true when maintaining a high-value service line (e.g., orthopedics, oncology, and cardiology) a competitor doesn’t offer. And person-centered medical care teams led by physicians and staffed with specialty or subspecialty APPs, for example, can help hospitals deliver comprehensive care and services that retail and urgent care centers cannot.
Modernize your APP recruiting
APPs have choices when it comes to practice settings: hospital, ambulatory, retail, telehealth, group practices, skilled nursing, and more. As a result, it’s difficult to attract and keep qualified practitioners.
Appeal to the most skilled APPs by showing that your healthcare system is contemporary and digital using the following software features and tactics:
- Eliminate paper and use a web-based recruiting module to track candidates’ applications and employment contracts throughout the recruiting process.
- Create or update position descriptions, offering marketappropriate compensation.
- Align each APP’s job description with state laws governing their scopes of practice.
- Stay informed of fast-changing licensure laws. Pay attention to physician supervision rules and prescribing rights, which are shifting rapidly to give APPs more independence.
- Manage candidates’ tasks and workflows as they move through your organization’s unique hiring process.
Integrate APP credentialing and enrollment
If an APP applicant will seek clinical privileges, and their services will be billed for, they’ll undergo credentialing. The credentialing process—and its major component, primary source verification (PSV)—should be just as robust for APPs as it is for physicians. Credentialing can be done in-house by the medical staff services function or an internal credentialing verification organization (CVO), or by an external, third-party CVO.
The initial steps of credentialing, application and PSV, are similar whether they’re conducted in unison or separately for two purposes:
- to credential and eventually grant clinical privileges
- to credential to enroll a provider into health plans, so the healthcare system can receive reimbursement for services
Increasingly, healthcare leaders see efficiency in structuring the credentialing process to achieve both goals. Further, enrolling APPs with CMS and/or private health plans requires attending to each payer’s unique regulations for billing. A contracts management application can navigate variances to ensure compliance and maximize reimbursement.
Today’s technology helps healthcare systems align the needs of credentialing and enrollment by:
- Eliminating risks associated with outdated payer or APP information. Inaccurate data on claims that are denied or falsely paid invites fraud and abuse investigations or fines.
- Managing claims data at the provider or practice location level by keeping payer information in one database, with notification, letter-writing, and reporting capability
- Tracking metrics to improve payer application turnaround times
- Determining whether to bill CMS for an APP’s services as “incident to” (under physician supervision), or individualized (using the APP’s own NPI number)
- Sticking to a follow-up schedule according to payers’ processing timelines, and document all details of communication—date, person spoken with, case number, etc.
Monitor APPs’ performance for quality
APPs who are credentialed and privileged through the hospital medical staff process require performance monitoring. Like physicians, APPs undergo ongoing professional practice evaluation (OPPE) and, if needed, focused professional practice evaluation (FPPE). OPPE and FPPE are TJC terms, but all hospitals must evaluate and validate providers’ performance at regular intervals, and under certain circumstances, according to their healthcare accreditation and/or regulatory body’s standards. These processes link provider competency assessment to privileges—and the right to deliver care or services to patients.
Performance data challenges that are unique to APPs include:
- The inability to find and track APP data, especially within supervisory arrangements
- The proliferation of team-based care, where multiple practitioners contribute to outcomes
- Absence of, or inconsistencies in, policies and procedures for monitoring APPs, especially when tying OPPE to reappointment for nonphysicians
- The growth of specialized APPs (e.g., oncology PA) who treat more complex or acute patients, thus requiring different measures than their peers and/or the associated physician specialty
In many healthcare systems, provider performance monitoring is shared by the quality and medical staff services functions, or even HR. For example, the medical staff may gather all or some of the performance data, but quality reports on it and is ultimately responsible for improvements.
If communication between departments is weak or policies are unclear, there’s a potential for data to fall between the cracks. A provider data software program that is a health system’s source of truth eliminates such risk.
Adhere to these risk-management practices to set your APPs and your organization up for success when evaluating care quality and practitioner performance:
- Document the OPPE and FPPE process for APPs in your bylaws and/or policies and procedures. Specify which nonphysicians undergo OPPE and/or FPPE, how often (e.g., time frames), who is accountable for reviews, and how information is documented.
- Specify which departments or functions contribute to the overall process. Accreditation body surveyors want to ensure processes are well documented and that established plans are adhered to.
- Identify the criteria/triggers for initiating a performanceimprovement plan.
- Choose meaningful, appropriate measures that accurately reflect APP performance, and describe the data collection method(s)..
- To the extent possible, involve APPs in the selection of the data (targets or indicators) used to measure their performance.
- Don’t rely solely on quantitative (i.e., data-driven) measures. Include qualitative (i.e., a narrative) in the report as well.
- Include the six core competencies in measuring APP performance, as you would for physicians.
APP software checklist
More change is certain for APPs in numerous areas: further practice expansion; quality, risk management, and performance monitoring strategies; and improvementimplementation oversight. Health systems that have handled APP data as secondary to physician data now realize that a sustainable credentialing software solution must also prioritize nonphysicians’ data management to:
- Handle credentialing of more facilities and individual APPs
- Increase the accuracy and speed of gathering primary source data, especially that related to licensure
- Enroll more APPs and track payer contracts, provider application status, and reimbursement time lines
- Generate reports and share key performance indicators specific to APPs
- Capitalize on the financial benefits of software as a service
- Automate more tasks by using web crawlers for verifications and fraud checks with licensure agencies, the Drug Enforcement Agency, the National Practitioner Data Bank, and the Office of Inspector General
- Provide increased self-service for users (including APPs) by allowing the import or export of data from external healthcare industry sources or internal entities, like a CVO
- Adapt templated applications, letters, and forms to maintain standardization of APP data across growing, multi-entity systems
Future-proof your health system’s provider data management by prioritizing APP data. With a software solution equipped to tap into APPs’ potential, what advantages could they provide your healthcare organization?
