Iris Telehealth recruits and hires top-notch clinicians and finds them placement in our partner facilities across the country, a process we call “matching.” Unlike many staffing agencies and locum tenens groups, these matches are meant to be as permanent as a typical onsite provider’s position would be. Providers are our employees and treated as independent contractors by the facility they are matched with. However, Iris is unique because we are advocates for both our providers and our partner facilities. This enterprise doesn’t work properly without both sides of the equation. By operating this way, we provide the best maximum outreach and positive community impact as possible.
The Clinical Operations Department at Iris is the intermediary between our clinicians and our clinics/hospitals. They act as the engine that implements matches, making it possible for services to be provided. Within Clinical Operations, we have Clinical Operations Managers as well as the Licensing and Credentialing team. Each match will have one Clinical Operations Manager and one Licensing and Credentialing Coordinator working on that implementation with the clinician and the partner facility.
I spent thirteen months on the Licensing and Credentialing team. Although I am currently transitioning to a different role within operations, I can attest to the fact that they are essentially efficiency machines. A typical day of my life in this role went a little something like this…
7:45 AM – 8:15 AM: This is when I would typically roll into the office, cold brew in hand. (That applies all year round, which I consider a benefit of living in Austin, Texas. No hot coffee for me, thanks!)
8:15 AM – 8:45 AM: As the detail-oriented person that I am, I spent this chunk of my morning looking through calendars and emails to ensure I knew what was going on around me and how I was going to spend my workday. I would get several requests from credentialing staff that were also going through their inbox, and I would jot them down on my list of tasks for the day. We work out of a credentialing database called Council for Affordable Quality Healthcare (CAQH) where providers fill out their profile and insurance companies use that to verify their credentials. As usual, several CAQH profile updates needed to be made, a few insurance enrollment-related forms needed to have doctors sign, etc.
8:45 AM – 9:00 AM: Credentialing Huddle! Every morning, our team would meet to discuss whatever the day’s topic was. On Mondays, we would discuss the week’s upcoming implementations and any foreseeable issues. Tuesdays were for discussing everyone’s individual goals for the day. Wednesdays were the outpatient huddle, where the Clinical Operations Managers joined us so we could give one another updates on each outpatient implementation in progress. Thursdays were Thoughtful Thursday, and we would each talk about something that was on our mind and influential in our work. Fridays were the weekly review with the entire Clinical Operations team where we would award informal kudos and talk about our wins that week. Today is Tuesday, and I let the team know I’ll be working on a Kansas medical license application, a few credentialing applications for my newest implementation, and spending the rest of the day doing license renewals.
9:00 AM – 10:00 AM: A new provider who made it through the majority of the hiring process submitted their credentialing application. I took time to review and export it into our credentialing database. I began pulling their file together and ensuring information in the application was accurate.
10:00 AM – 11:00 AM: This was my weekly meeting with Annie, our team lead. We reviewed my open licenses and credentialing files, I provided updates on their status, and we brainstormed solutions for roadblocks that were causing delays. Telepsych is a unique industry that doesn’t fit neatly into the established rules and regulations for most medical complexes. Every state medical board, Medicaid program, DEA office, etc. is different in their requirements and timelines. Our doctors live and work all over the country. While we can’t be experts in every state, we can both pool our knowledge as a team and get really good at perusing Google search results. We come up with creative strategies to make things move faster and happen, even when the surface-level answer is “no.”
11:00 AM – 12:30 PM: I started and completed the initial application for the Kansas medical license I was assigned that morning. I sent out initial requests to people that needed to complete forms on the provider’s behalf – their references, postgraduate training program, medical school, etc. I prepped a lengthy email with fingerprinting instructions for the provider to complete a background check submission.
12:30 – 1:00 PM: I realized what time it was, checked if anyone else was going to eat lunch, and warmed up something that probably was in my fridge for multiple days. The miserably hot Austin summer had already begun, but we ate lunch on the patio anyway.
1:00 PM – 1:30 PM: I found out that there was an issue with Florida Medicaid not reimbursing one of the three providers I’ve implemented at a clinic. I hopped on the phone, and after many transfers and hold periods, I found out that the hold-up is due to a seemingly insignificant spelling discrepancy. I informed the clinic of how they needed to proceed to correct the mistake – crisis averted!
1:30 PM – 3:00 PM: I powered through the three credentialing applications I needed to complete for one of my implementations. I was introduced to the clinic’s credentialing team in the morning, and I want to get the provider’s information to them as soon as possible. I filled everything out that I could, sent it over to the clinic (along with the supporting documentation I had on file), and informed the provider that I needed a copy of their undergraduate diploma to proceed. I also sent the provider step-by-step instructions on how to get their drug screening and background check completed.
3:00 PM – 3:30 PM: I worked with a new partner of ours. They had never had telepsychiatry or telemedicine of any specialty in their clinic before, so they were unfamiliar with how to properly credential our telepsychiatry provider. Some questions they had were:
“Do we need to complete insurance enrollments, or does Iris take care of that?” I explained to them that they will panel the provider with the same insurance groups their onsite doctors are paneled with, and that our credentialing team does not take care of billing, but we do assist with enrollments as needed and facilitate gathering original signatures from the provider. The clinic already had the infrastructure to take care of billing and insurance credentialing, so while we do everything we can to assist with applications and anything else needed, this responsibility lies with the partner.
“Are there things that Iris has already verified that we don’t need to take care of?” I let them know that Iris does our own internal credentialing process, but the clinic will still need to complete their normal credentialing. We are aiming to become accredited with the Joint Commission, so we should be able to complete credentialing by proxy in the future, but for now we cannot offer that under most circumstances. I listed out the documentation I already had on file for the provider as part of our process: diplomas, board certificates, etc., and said I would send over whatever else they may need. Even though we can’t eliminate their credentialing process, we try to make it as effortless on their part as possible, especially for the clinician.
“If they have to go through our credentialing process, they will be required to provide proof of immunizations.” Our providers are normally exempt from requirements like this since they are not working onsite and interacting with patients, which is a benefit of telemedicine this clinic had not run into before. This would only be necessary if it was within the partner’s bylaws and therefore unavoidable. The clinic agreed after hearing this explanation that providing proof of immunizations would be unnecessary. One less requirement to check off the list, and that much faster that our clinician can get to seeing patients!
3:30 PM – 3:40 PM: I got a call from one of my providers that I was getting a California license for. They had clarifying questions about the fingerprinting process and what exactly they needed to bring with them. I answered their questions, discussed what to expect next, and the provider scheduled their fingerprinting appointment.
3:40 PM – 4:00 PM: It had been several weeks since a provider’s medical license application was marked complete and in final review. I spent this time on hold with the board for a status update, and I found out there was an oversight. They said they’ll issue the license in a few days. (Surprise – it doesn’t get issued, and I called the licensure analyst back a few days later.)
4:00 PM – 5:00 PM: Today was our monthly credentialing postmortem meeting. The team gathered to discuss issues, mistakes, and lessons learned from the past month. The topics can range from something as small as an error on an application causing a short delay in processing a license application to something much more consequential. Every mistake is a learning opportunity, and with fifty states worth of regulation, we run into a lot of learning opportunities! At the end of the meeting, we blind-graded ourselves on our general success that month in our resolutions. I graded myself a B+. Once the grades were revealed, our average for the month was approximately an A-.
And that’s how it’s done, folks! This is a fairly typical day in the schedule of one of our Licensing and Credentialing Coordinators. Every day is a little different, though, and that’s what keeps it exciting! Telemedicine is an ever-evolving field with plenty of challenges and hoops to jump through. We take it one hoop at a time.
What is Medical Credentialing?
If you haven’t worked in the medical field before, you might be wondering what credentialing even is.
Credentialing is the process of establishing the qualifications of licensed medical professionals and assessing their background and legitimacy.
Credentialing is often seen as a necessary evil for clinicians. If a physician graduated from medical school, completed a residency and possibly a fellowship, was licensed by a medical board, and has years of experience – why do their credentials need to be scrutinized all over again to work somewhere else? Why is patient care being delayed until another set of eyes verifies their history and competency?
What is Included in Medical Credentialing?
Hospitals and clinics have a duty to their patients to thoroughly evaluate the experience and skills of their medical staff and can be held liable for patient injury or mistreatment if they fail to do so. They will typically review and collect documentation for:
- Medical education
- Postgraduate training
- Medical licenses – active and historical
- DEA registrations
- Controlled substance registrations
- Continuing education credits and compliance
- Board certifications
- Employment history
- Privileges/affiliations history
- Professional liability insurance policies held
- Malpractice claim history, including statements from the clinician and court documentation, if applicable
- Peer reference evaluations
- Federal and/or state background check, often completed via fingerprint collection
- Health screenings – drug/alcohol test, general physical assessment, anything necessary for physical interaction with patients such as a TB test or flu shot
- Online databases – the National Practitioner Data Bank, the Office of the Inspector General’s exclusion database, Medicare’s Opt Out Affidavits database, etc.
- Personal identification – driver’s license, passport, social security card, etc.
- Clinician’s personal attestation history
- Disclosure of conflicting financial interests
The list goes on and can vary from facility to facility based on their bylaws and group accreditation requirements. The purpose is the same – to protect the population from medical negligence and malpractice. While it would seem that a physician “passing” the credentialing assessment from one facility would mean subsequent facilities should follow suit, history has proven that this assumption can be a dangerous one.
The Beginning of Medical Credentialing
The first instance of physician vetting was in 1000 BC. In Persia, followers of the ancient religion Zoroastrianism created a system for deciding whether or not a doctor was allowed to practice medicine. The doctor had to successfully treat at least three nonbelievers in medicine, and only if all three survived were they eternally deemed qualified to practice medicine.
The beginnings of medical school appeared around the 13th century in Sicily, well before the concept of the medical license. Physician candidates had to meet certain qualifications in order to attend and pass an exam given by a surgeon so they could practice. Regulation and restriction around the practice of medicine has substantially evolved since then, but the notion that physicians must prove their worthiness has been around for centuries.
Historical Landmarks in Credentialing
Darling v. Charleston Community Memorial Hospital in 1956 was the landmark case identifying negligent credentialing. Dr. John Alexander set a cast on a broken leg, but he wrapped it too tightly, ultimately cutting off circulation in the leg. The patient was transferred to another hospital, underwent several surgeries by the head of orthopedic surgery, and eventually had the leg amputated due to necrosis caused by the restricted circulation. Dr. Alexander claimed he had set hundreds of legs in the past, but he had actually only set two ankle fractures since working at this hospital. He was not exposed to orthopedic material in medical school, had no subsequent training on how to set a broken leg, and did not bother to consult the board-certified orthopedic surgeons available at his hospital.
The patient sued the physician, but what makes the case memorable is that he also sued the hospital for letting Dr. Alexander set the leg with no orthopedic training. The hospital did not require him to consult a specialist on staff or provide proof of up-to-date continuing education around operative procedures during credentialing. He also sued the hospital for their unskilled nurses not identifying the lack of circulation earlier. Both Dr. Alexander and the hospital were found liable.
This was the first time a hospital was held responsible for the negligence of an affiliated physician originating from a lack of credentialing. Physicians traditionally operated as independent contractors for hospitals and were not employees, but this court decision shifted a portion of the responsibility from the medical staff to the hospital itself. It confirmed that physicians are extensions or representatives of the hospital when they are practicing in the hospital, unlike a typical contractor role where the employer bears little responsibility. The uniqueness of this case is the hospital’s liability for the physician’s torts, as well as the hospital having an independent duty to provide safe, quality patient care.
In 1981, Johnson v. Misericordia Community Hospital found the hospital liable for Dr. Lester Salinsky’s malpractice due to a lack of thorough credentialing. After Dr. Salinsky paralyzed a patient during a hip surgery, it was discovered that he had lied on his application, stating he had never had previous privileges suspended, omitting any information on his malpractice insurance, and attesting that he was only requesting privileges for skills he was qualified to perform. Many of the hospitals he listed as being affiliated with had never actually had him on staff. He was not board-certified in orthopedic surgery as he had claimed–or even board-eligible! There were seven cases of malpractice against him that he had failed to disclose to the hospital, and three more suits were filed against him during his appointment at Misericordia.
There was no organized credentialing committee at the time of Dr. Salinsky’s appointment; the executive committee took on those responsibilities at the time. The executive committee failed to actually contact his references or verify his past privileges. A medical staff coordinator thought Dr. Salinsky had already been on Misericordia’s medical staff before she began working with the executive committee, so she passed the file along. Her assumption that he had been credentialed once, so he was qualified to be credentialed again, led to a grossly incompetent surgeon being allowed to practice in an environment where he caused undue injury to a patient. The case was considered corporate negligence of the hospital because Misericordia did not adhere to the duty they owed their patients to protect them from foreseeable harm. It was the hospital’s responsibility to investigate and find the truth, despite Dr. Salinksy’s lies on his application for appointment.
Credentialing is a Necessary Evil
That, ladies and gentlemen, is why credentialing and re-credentialing are important. The repetitive and detailed nature of credentialing is designed to protect patients and ensure the legitimacy of that expensive piece of paper a physician walks out of medical school with. However, it is possible to improve the efficiency and speed of credentialing without compromising quality, and our team at Iris Telehealth does a fantastic job of that. Our main goal as a telemedicine company is to bridge the gap in the availability of psychiatric care across the country. We can only be successful in this goal if we prioritize quality care, making thorough, diligent, and efficient credentialing our priority.
About Iris Telehealth
Iris Telehealth is a telepsychiatry provider organization made up of the highest quality psychiatrists and psychiatric nurse practitioners. Our mission is to provide underserved communities with access to the best mental health specialists and prescribers. We are owned and operated by doctors who understand what patients need and have earned a reputation for providing outstanding customer service. Iris values building strong professional relationships with our partners and their staff. We are dedicated to understanding your organization’s needs and operational goals because we recognize that your success is critical to our own.
Iris Telehealth has helped countless hospitals and community health organizations across the country add telepsychiatry to their list of services. We believe everyone should have access to compassionate mental health care, and we have made it our mission to find innovative, affordable ways of making this possible!