Navigating APP credentialing and privileging laws

Credentialing and privileging regulations for advanced practice professionals (APP) are currently a loose patchwork of federal and state statutes. Given this variability, today’s discussion centers on strategies that MSPs and medical staff leaders can use to identify and apply relevant laws to their APP vetting processes.

The starting point is at the state level, where the applicable practice act specifies what an APP can or cannot do and sets forth any restrictions on where the APP can practice. In some states, statutory provisions will specifically permit hospitals and other health facilities to credential and privilege certain categories of APPs.

In general, state laws addressing credentialing and privileging of APPs tend to defer to an institution's governing body and medical staff to regulate APPs at the institution. Therefore, it becomes critical to have medical staff bylaws that adequately address the role of APPs and contemplate the various issues that may arise with respect to APPs' practice.

At the federal level, the Medicare Conditions of Participation acknowledge that a Medicare-participating hospital's "non-physician practitioners" may be members of the hospital's medical staff, as long as their membership is consistent with state law. So even for purpose of federal Medicare regulations, state law is important in establishing what an APP can and cannot do from a medical staff perspective. Relatedly, note that The Joint Commission Hospital Accreditation Standards, which many hospitals follow in order to participate in Medicare, provide that all "licensed independent practitioners" (i.e., any individual who may provide services without direction or supervision) must be credentialed and privileged through a hospital's organized medical staff. The standards go on to call out, in particular, physician assistants and advanced practice nurses who are not licensed independent practitioners as eligible for privileging through the medical staff process or a "procedure that is equivalent to the medical staff" and that meets the same criteria to which medical staffs are subject.

The National Practitioner Data Bank (NPDB) is another area of federal regulation that is relevant to credentialing and privileging of APPs. The NPDB is the federal repository that collects information that may reflect poorly on a provider's competence and quality of care, such as malpractice awards and adverse peer review actions. In the medical staff context, hospitals and other providers must report to the NPDB adverse peer review actions against physicians, but they have discretion whether to report adverse peer review actions against APPs. However, hospitals must query, or request, information regarding APPs from the NPDB during the credentialing process; there is no discretion. Thus, as pertains to APPs, reporting adverse peer review actions to the NPDB is optional, but querying that same information is not. With respect to reporting, providers should bear in mind that even though federal law does not mandate reporting of adverse peer review actions to the NPDB, state law may require reporting these actions to a state agency or database.