Credentialing is the process of obtaining and reviewing a clinicians documentation to determine a status of participation privilege in a health plan. Documentation should be provided by the applicant and must include their education, clinical privileges, accreditation, certifications, professional liability insurance, malpractice history and professional competence.
To become credentialed for the first time, you will provide:
- Attestation, signature and date
- Curriculum Vitae
- Work history (month/year format)
- Copy of DEA and/or CDS certificate
- Copy of malpractice insurance
- Summary of pending or settled malpractice cases if applicable
Why is health quality measured and reported?
It gives consumers and employers the basis to make informed decisions and pursue the best available care. It also gives feedback to health plans, medical groups, and doctors to improve quality issues.
How is it measured?
Surveys (on and off-site), audits, satisfaction surveys, clinical performance measurements, and more. We use these approaches in a range of accreditation, certification, recognition and performance measurement plans for different types of organizations, medical groups and even individual physicians.
How does Optimus ensure compliance?
At Optimus we gather quality information and make it available to consumers, employers, health plans and doctors through these strategies:
- Ensures compliance with applicable regulations related to coding and documentation guidelines for Risk Adjustment (federal, state, and county laws).
- Thorough review of patients’ medical records, inclusive of patient medical history and physical exams, physician orders, progress notes, consultations reports, diagnostic reports, operative and pathology reports, and discharge summaries in order to verify whether:
- the diagnosis codes are supported by the documentation and comply with ICD –10– CM Guidelines for Coding and Reporting.
- the diagnosis codes for each chronic or major medical condition have been captured and submitted within the permitted timeframe.
- any diagnosis code is unsubstantiated by the record and should be eliminated. A review is applicable for clinical indicators and query providers to capture the severity of illnesses of a patient.
How do we ensure reimbursement?
Optimus MSO ensures consistent physician and facility reimbursement by automatically evaluating provider claims in accordance with accepted industry coding standards thanks to a comprehensive nationally recognized code auditing system to secure consistent physician and facility reimbursement. We constantly enhance and update our code-editing technology to better enforce existing payment guidelines.
Claims will be reviewed to:
- Reinforce compliance with standard code edits and rules.
- Ensure correct coding and billing practices are being followed.
- Determine the appropriate relationship between thousands of medical, surgical, radiology, laboratory, pathology and anesthesia codes.
- Ensure compliance with industry standards.
Correct coding guidelines are established by:
- The Centers for Medicare and Medicaid Services (CMS).
- The American Medical Association (AMA) CPT Coding Guidelines.
- National and Local Coverage Determinations (NCD/LCDs).
- National specialty and academy guidelines.
The Healthcare Effectiveness Data and Information Set (HEDIS) is used by 90% of health plans in the U.S.
It ensure health plans are offering quality preventive care and services to members and consists of a set of performance measures.
Is HEDIS mandatory?
HEDIS annual reporting is mandated by all regulatory agencies. As such, it is extremely important that providers and their staff members become familiar with HEDIS to understand what health plans are required to report.
How does it work?
To ensure the validity of HEDIS results, all data is rigorously audited by National Committee for Quality Assurance (NCQA) certified auditors using NCQA’s process, which has expanded the size and scope of HEDIS to include measures for physicians, PPOs, and other organizations. Data is collected via HEDIS Data Submission including Healthcare Organization Questionnaire (HOQ) and Interactive Data Submission System (IDSS).
Code acurracy determines proper payment
It is of the upmost importance that providers submit accurately coded claims/encounters data for each service provided. In order to guarantee that we collect properly coded administrative data, we have developed a tool to assist our providers correctly code services rendered. HEDIS is a registered trademark of the NCQA.
Anticipation: key to patient’s care and safety.
We organize and coordinate all patient care activities and share the information between all parties involved with a patient’s care, to ensure effective and safe care. We make sure that a patient’s requirements are known ahead of time to the right people.
The Optimus approach
- Team coordination to improve access and quality of care for patients at any of the health centers.
- Efficient methods of communication, including daily hospitalization reports.
- Ensure follow-up of patients after hospitalization.
- Quality control in patients care, of all age groups and stages of development.
- Prepare, special reports and analyzes, upon request.
- Track, monitor, and actively manage assigned patient cases to ensure coordination of care, retention of patient and a high level of utilization.
- Retrieve all elements to build a patient’s longitudinal care record.
- Interact with patient’s physicians and other staff both within the clinic and outside facilities providing accurate, timely and responsive information.
Let Optimus manage your practice pharmacy needs, to ensure effective compliance and safety.
Our comprehensive pharmacy management service includes:
- Organizing and reviewing pharmacy policies and procedures in every medical office.
- Establishing satisfactory methods of drug prescription and control.
- Establishing quality specifications for all drugs and chemicals used by PCP in accordance with the recommendations of the Pharmacy and Therapeutics Committee of CMS.
- Explaining policies and procedures in Pharmacy, department objectives, operations, services, and organization.
- Record keeping, assuring quality, quantity and timeliness of work done. Reviewing and appraising work of others within the department.
- Preparing reports and special studies; participating and contributing to management and professional committees at all level inside and outside of the medical center.
- Reporting on trends to assigned functions and changes insides and outside the medical center.
- Maintaining care competency as indicated by orientation guidelines for a particular unit, for patients of all age and stages.
- Establishing notification procedures for drug interactions and high-risk medications for the geriatric patient.