The Greeley Company is a full-service healthcare consulting practice with specialties including Compliance & Quality, Bylaws & Governance, Medical Staff Optimization & Physician Alignment, External Peer Review, Credentialing & Privileging, Interim Staffing, and Education & Seminars. 888-749-3054 | www.greeley.com
Key KPIs to help new leaders assess current state, set goals
New eyes are on the medical staff services department (MSSD) as healthcare organizations place greater urgency on optimizing credentialing, privileging, and enrollment processes. “More and more, the MSSD is recognized as critical to hospital revenue and a key driver of practitioner satisfaction,” says Sally Pelletier, CPMSM, CPCS, advisory consultant and chief credentialing officer with The Greeley Company.
As a result, many MSSDs are undergoing significant transformations, with some departments under new leadership with finance, operations, and even marketing titles. MSSDs are also seeing certain functions shift to centralized corporate structures to standardize processes and onboard practitioners more quickly, according to the new brief How to Optimize and Right-Size the Medical Staff Services Department.
“Although these changes are positive for MSSDs and their organizations, a new leader stepping into the department may not find their footing so easily, especially if they are not trained as a medical services professional (MSP),” says Pelletier. “Each MSSD is unique and has a high degree of variability in its work scope. Non-MSP leaders will need support and training as they begin to assess staff roles and department processes.”
The brief describes the five things all successful MSSDs have in common that new leaders must know. They include having clear core functions and an adaptive and strategic approach to right-sizing FTEs. There are also five key performance indicators (KPI) MSSD leaders should pay close attention to that tie directly to compliance, provider satisfaction, and revenue, says Pelletier. “These KPIs can help measure the efficiency of the department’s core functions and serve as common ground for base-level assessments and for setting goals and measurements.” Go here for more information on how to evaluate your MSSD’s current state and explore opportunities to optimize and right-size.
Using proactive external peer review to mitigate the risk of high-dollar lawsuits
Medical necessity investigations and lawsuits are a significant threat to healthcare providers, especially those that rely on internal medical staff peer review programs to identify adverse patterns in clinical behavior, according to the new brief Medical Necessity: Checks and Balances Most Hospitals Don't Have, but Should.
"All too often, the medical staff is not up to the task of policing for medical necessity and therefore does not produce adequate oversight," says Rick Sheff, MD, chief medical officer and national director of external peer review at The Greeley Company. As a result, healthcare executives may not know the extent to which their organizations are at risk for fraudulent billing.
This is a critical issue, given the OIG has recently settled numerous multimillion-dollar lawsuits with hospitals and physicians for performing medically unnecessary tests and procedures.
Whistleblower lawsuits in particular are damaging to a hospital’s reputation and bottom line. "There is no shortage of people willing to blow the whistle in medical necessity cases and retire comfortably for their trouble," says Thomas Anthony, an attorney with Frost Brown Todd LLC. Whistleblowers receive between 15% and 30% of the amount recovered by the government.
Hospitals face big risks when the medical staff peer review process does not lead to medical necessity decisions that match OIG guidelines.
The brief describes how to establish an effective medical necessity surveillance and accountability program. One key step includes creating an external peer review process, which is a best practice for hospitals looking to reduce risks related to medical necessity. Experienced external peer reviewers not only perform impartial assessments, but also raise the red flag when self-reporting might be warranted. Go here to learn how to structure and implement medical necessity checks and balances.
The right aging policy can prevent serious issues that jeopardize patient safety—while still protecting older practitioners.
It is no longer uncommon to see practitioners working well into their 70s, 80s, and even 90s. In fact, the number of physicians age 65 and older has more than quadrupled since 1975. Older practitioners bring critical knowledge, experience, and mentoring to their profession. However, as people grow older, their performance changes due to cognitive and physical decline—and practitioners are no exception.
“This is why it is critical to have an aging practitioner policy,” says Sally Pelletier, CPMSM, CPCS, advisory consultant and chief credentialing officer with The Greeley Company. In the new briefTaking a Commonsense Approach to Aging Practitioners, Pelletier says that despite strict regulations and rules requiring practitioners to be mentally and physically able to perform their requested clinical privileges, these rules do not always catch issues related to aging. For example, peer review might fail because criteria used to measure competency in older practitioners do not specifically address changing mental acuity and physical decline.
An aging policy enables hospitals to provide quality patient care and reduce their risk of negligent credentialing, while making sure that older practitioners are treated objectively and consistently.
The brief describes five key areas an aging policy should cover, including credentialing, privileging, and mental and physical assessments. Establishing a strong framework from the start—with a seasoned physician champion and a facilitative coach who can lead policy design decisions—will result in an aging policy that works for both practitioners and hospitals. Read more here about how to create an effective aging policy.
A well-structured, adaptable medical staff services department (MSSD) can make a real difference in today’s changing healthcare landscape.
Mergers and acquisitions continue at a rapid pace, regulatory challenges are increasing, and payment models are evolving, all of which make the credentialing, privileging, and enrollment functions of the MSSD crucial.
Increasingly, MSSDs are being tasked with larger objectives, including improving the bottom line, overall clinical quality, and accountability. To do this, the MSSD must be flexible—it must adapt.
In a new brief, Sally Pelletier, CPMSM, CPCS, advisory consultant and chief credentialing officer with The Greeley Company, describes the importance of getting the department’s architectural blueprint right while continuing the department’s essential daily work. Pelletier pinpoints the value of getting the MSSD out of day-to-day reaction mode and into a proactive mindset that allows it to be nimble no matter what (inevitable) change comes next.
Investments in preparing and optimizing the MSSD for higher functions can show returns on investment in the day-to-day, as well. Revenue-impacting improvements include reduced turnaround time in credentialing and privileging, which can get new physicians earning faster, and reduced claims write-offs if delegated status with payers can be achieved.
The brief covers the importance of architecting an MSSD properly. You can read more about how to optimize the MSSD for day-to-day operations and greater organizational responsibilities here.
Today, physician peer review in most organizations is a matter of simply going through the motions. While this might meet regulatory requirements, there’s no real value gained from the act, much less any benefit in terms of overall physician performance. When conducting peer review, organizations are using part of their revenue from patient care to improve their provision of that care; it’s an investment that demands a return, yet many organizations do not get one. How can organizations move from these ineffective routines to conduct peer review that works—and promotes continuous improvement?
In this Q&A, Rick Sheff, MD, chief medical officer for The Greeley Company, shares the seven secrets The Greeley Company uses to help their clients get real value out of peer review.
Peer review started out as punitive and acquired a reputation as biased. In this Q&A, you’ll learn how to drive out bias, and how to use rule and rate indicators to create a neutral environment of measurement and feedback. In addition, you will discover why using a single target for all rate indicators is one of the biggest pitfalls for peer review—and how to move beyond this practice. Also, you’ll learn why the management style of a physician culture within an organization is critical to balanced peer review.
Taking inspiration from manufacturing industries, you’ll learn how to use continuous performance improvement from everyone in the organization to positive effect, whether the organization is a solid performer or an underachiever. You will also learn why, even though state disclosure laws may discourage effective peer review, the need for such peer review is stronger than ever. Lastly, are you appreciating your physician employees? If not, all your efforts to rev up peer review could fall short. This Q&A will demonstrate why appreciation is the element that could separate a successful program from an unsuccessful one.
Once physicians learn the seven secrets to getting real value out of the time and effort they put into peer review, most will embrace them. Then, the organization can train physicians to lead and perform peer review themselves, creating a virtuous cycle. If the culture isn’t ready for this change, it’s often helpful to start with an assessment that identifies what’s being done well in peer review and the major opportunities for improvement. Either way, once organizations implement the seven secrets to peer review, they’ll never want to go back to their old wasteful ways. Download this Q&A here.