Credentialing, Accreditation, and Certification: What the Radiologist Needs to Know - PowerPoint PPT Presentation


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Credentialing, Accreditation, and Certification: What the Radiologist Needs to Know


Credentialing, Accreditation, and Certification: What the Radiologist Needs to Know A Special Thank You to: Dr. David M. Yousem, M.D., M.B.A. – PowerPoint PPT presentation

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Title: Credentialing, Accreditation, and Certification: What the Radiologist Needs to Know

Credentialing, Accreditation, and Certification
What the Radiologist Needs to Know
A Special Thank You to Dr. David M. Yousem,
M.D., M.B.A.?Professor, Department of
Radiology?Vice Chairman of Program
Development?Director of Neuroradiology?Johns
Hopkins Hospital for allowing the use of his
material/content in this presentation Dr.
Yousems online lecture series can be viewed
at http//
a86f83b011 Dr. Yousems project was funded
through an RSNA Educational Grant
In this presentation we will discuss
  1. What is Credentialing? Who provides it and why is
    it needed?
  2. What is Accreditation? What is it important?
  3. What is Certification and Maintenance of
    Certification? How and when is it obtained?

What is Credentialing?
  • Credentialing is a systematic review process used
    by a hospital or managed care organization (MCO)
    to assess and confirm that a physician is
    competent and qualified to practice medicine in
    their designated field
  • The landmark Darling v.Charleston Hospital case
    in the 1960s established that hospitals had an
    obligation to verify the competency of the
    physicians who practice within its walls, and
    thus credentialing was born

Credentialing Committee
  • Each hospital or MCO will have their own
    credentialing committee
  • The committee is composed of various health care
    workers doctors, nurses, physician assistants,
    administrators, etc. Having a radiologist on the
    committee is ideal since the committee determines
    the criteria necessary to grant specific
    privileges to individual physicians
  • The committee also collects, reviews, and
    verifies various documents to ensure that a
    physician meets 6 core competencies medical
    knowledge, technical skills, clinical judgment,
    interpersonal skills, communication skills, and

Credentialing Support Databases
  • Committees can use various credentialing support
    services to verify physician information
  • National Practitioner Data Bank
  • Provides information regarding malpractice
    claims, restrictions of privileges, professional
    society adverse sanctions, licensure actions by
    state boards, DEA reports, and CMS exclusion
    actions. Check your status at www.npdb-hipdb.hrsa.
  • Healthcare integrity and Protection databank
  • Discloses any fraudulent Medicare or Medicaid
    claims American
  • Board of Medical Specialties
  • DEA, CDS, Centers for Medicare and Medicaid
    Services (CMS)

Delay or Denial of Credentialing
  • There are particular RED FLAGS that can delay or
    deny credentialing
  • Personal conduct history - Poor references
  • Deferred letters - Alcohol or substance abuse
  • Multiple malpractice suites - Short employment
  • Unexplained gaps in employment or education
  • If there is a high risk that credentialing will
    be denied, it is in the best interest of the
    physician to resign before the committee
    investigates or makes their conclusion, as this
    denial of credentialing will remain on the
    physicians permanent record

Delineation of Privileges
  • The Credentialing committee also determines each
    physicians privileges depending on their specific
    training and skill level
  • For example, the committee can specify the
    minimum number of CT, MR, US, myelograms,
    biopsies, etc that must be read or performed in a
    specific amount of time to obtain/maintain
    specific privileges
  • Again, it is important for a radiologist to be on
    the committee to help determine these criteria
  • These criteria ensure physicians, both
    radiologist and non-radiologist, are competent in
    their areas of care

  • Once credentialed by a hospital, a physician must
    apply for recredentialing every 2 years to
    maintain their privileges

Why is Credentialing Important?
  • A physician MUST be credentialed by a hospital to
    work there
  • Part of credentialing is delineation of
    privileges for every hospital staff member,
    ensuring a physicians competence in their
    particular skill set

What is Accreditation?
  • Accreditation of a health care facility ensures
    that it is maintaining a high standard for the
    quality and safety of health care delivery
  • The Joint Commission (formerly the Joint
    Commission Accreditation of Healthcare
    Organizations - JACHO) or the American
    Osteopathic Association (AOA) has the ability to
    accredit hospitals
  • Periodic inspections and reviews
  • The National committee for Quality assurance
    (NCQA) is a nongovernment agency that accredits
    MCO, PPOs, health plans, etc
  • The American College of Radiology (ACR) accredits
    imaging facilities

ACR Accreditation of Imaging Facilities
  • ACR sets protocols and guidelines for imaging
    facilities to ensure image quality, equipment,
    and reporting meet the highest standards in
    quality and safety
  • ACR evaluates the imaging equipment and the
    physician in a practice setting
  • This includes radiologists and non-radiologist
    imagers such as cardiologists, orthopedists,
    chiropractors, or any physician using imaging
    equipment in their practice

ACR Accreditation
  • Factors evaluated by the ACR
  • Image quality
  • Film storage and handling
  • Patient identification
  • Right and Left marker placement
  • Written reports
  • Frequency of equipment inspection

Why is ACR Accreditation Important?
  • It not only ensures the quality of imaging and
    reporting but is also REQUIRED by some insurers
    to be reimbursed
  • Accreditation also restricts non-radiologist from
    obtaining inadequate images or from obtaining
    images but not providing written reports
  • More information regarding ACR accreditation can
    be found on their website,

What is Certification?
  • Certification is a lifelong process by which the
    ABR and/or ABMS ensures that you, as a
    radiologist are adequately qualified and are
    involved in continued learning and improvement
  • There are two certification processes, both of
    which are awarded by the ABR
  • Initial certification
  • Maintenance of Certification (MOC)

To Apply for Initial Certification you must have
  • 5 years of approved training
  • 1 year clinical
  • 4 years in Diagnostic Radiology, which includes 4
    months of Nuclear Medicine, 3 months of
    Mammography, and no more than 12 months in any
    one discipline
  • Passed all ABR examinations
  • Currently Physics, Written, and Oral
  • For the 2012 class and forward a Core
    examination during R3-R4 year and Certifying
    examination 15 months after R4 year
  • Cardiac life support certification, high moral
    and ethical standards, and proof of valid state
    licensure or Canadian equivalent

Certification and Recertification
  • You have a 10 year period after completing
    training in which to obtain initial
    certification, which is valid for 10 years
  • You must then apply for Recertification through
    the ABR and/or American board of medical
    specialties (ABMS) to continue practicing as a

MOC Recertification
  • To become recertified, you must practice
    radiology, maintain an active unrestricted
    license and professional standing, pass the
    Maintenance of certification (MOC) exam, and meet
    the following specific requirements over a 10
    year period
  • 250 CME credits - 20 SAM
  • MOC exam - 3 PQI projects

Specific Recertification Requirements A Closer
  • 250 category 1 CME credits
  • 70 in a subspecialty or area of practice, 30
  • 20 SAM (self assessment modules, each is 90 min)
  • 4 SAM must be in general knowledge, 16 in
    clinical content
  • At least 6 need to be subspecialty specific
  • May overlap with the CME requirement
  • SAM can be found on the ACR or subspecialty
  • MOC examination
  • Comprehensive 4 hr knowledge based computer test
  • 80 clinical content, 20 non-interpretive skills
    including safety, life support, ethics, physics

Specific Recertification Requirements A Closer
  • 3 PQI (Practice Quality Improvement) projects in
    10 years
  • PQI project is a means of self-evaluation and
    continued quality improvement
  • The project must be in one of these five areas
    patient safety, accuracy of interpretation,
    report timeliness and critical value reporting,
    referring physician services, practice
  • PQI projects can be designed by an individual
    radiologists, radiology practice groups or
    departments, institutions, healthcare systems, or
    by professional radiology societies
  • Every radiologist participating may receive PQI
    credit for the project
  • More PQI information can be found at

  • Credentialing is hospital based process which
    ensures physician competence and delineates
    physician privileges
  • Accreditation of a facility by the ACR assures
    imaging quality standards and is required for
    insurance reimbursement
  • Certification and MOC by the ABR ensures that
    radiologists are involved in continuous learning
    and self-improvement