Follow standards for verifying postgraduate training

In the book Verify and Comply: Credentialing and Medical Staff Standards Crosswalk, sixth edition, co-author Carol S. Cairns, CPMSM, CPCS, shares tips and best practices for complying with CMS CoPs and other accrediting bodies’ standards. Below is her advice for verifying a medical staff member’s postgraduate training on initial application.

According to CMS Conditions of Participation, the medical staff must have a mechanism to examine evidence of training and documented experience. CMS does not specify acceptable sources for this evidence.

To verify training, an MSP would need:

• A documented phone call with the postgraduate training program

OR

• Verification from:
  • The AMA Physician Masterfile for all US and Puerto Rico postgraduate training programs
  • The AOA Physician Database

A best practice that exceeds CoPs is:

• Criteria-based evaluation form completed by postgraduate training program documenting clinical competence.

Tips:

1. In certain instances, foreign institutions will not or cannot verify training. In that case, efforts to obtain primary source verification should be documented. The organization may be able to verify training and experience with individuals who trained with the applicant who are now practicing in the US.
2. In the case of an applicant who has completed postgraduate training many years ago (e.g., 15-20 years), simple verification of completion of training may be sufficient (i.e., from training program, AMA, AOA).
3. The medical staff should establish policies guiding the credentials verification process.