Chapter 5: Clinical Staffing – Credentialing and Privileging Assurances for Contracted/Referral Arrangements

The HRSA Site Visit Protocol (SVP) asks, during the FQHC site visit, “Was the health center able to ensure through provisions in contracts or through other means (e.g., health center review of the contracted organizations’ credentialing and privileging processes) that contracted services (Form 5A, Column II) and referred services (Form 5A, Column III) are provided by organizations that:

• Verify provider licensure, certification, or registration through a credentialing process?

• Verify providers are competent and fit to perform the contracted service(s) through a privileging process (HRSA Site Visit Protocol, p. 24 and 25)?”

A question frequently raised is, “Which Column II and III services do I need to ensure they credential/privilege their providers?” “Do I need those assurances for ‘Transportation Services’?” “Screening Services?”

The HRSA Site Visit Protocol and HRSA Compliance Manual are not clear on this, but this is my trusty rule-of-thumb that has not let me down yet: “If your health center was providing that service directly (Column I) and your policies would require you to credential and privilege those employees, then you also need to have documented assurances that those services utilize appropriately credentialed and privileged staff.”

For example, if your health center had a pharmacy on-site, would you credential and privilege your pharmacist or pharmacy tech? Yes. Then you should also have assurances that your Column II contract pharmacy also credentials and privileges their staff.

Or, if you had a transportation service (a person that drives a van around to pick up patients for visits) provided by your health center, would you credential and privilege that driver? No. Then you do not need to have assurances that your Column III transportation company credentials and privileges their drivers.

The next question typically is, “How do we provide these assurances?” or “Do I need to maintain the credentialing and privileging files for all the clinical staff for all of our contracted or referral organizations?”. First, the health center CAN maintain the credentialing and privileging files for all of the clinical staff for all of the organizations-this is one type of assurance. However, that is often not practical or realistic in most cases. The HRSA Site Visit Protocol lists several suggestions for how health centers might provide those required assurances, including documenting “the assurance that the health center has reviewed:

• The contracted organization’s credentialing and privileging processes for providers, such as physicians, pharmacists, and dentists;

• The contracted organization’s documentation from a nationally recognized accreditation organization; or

• The contracted laboratory’s documentation of Clinical Laboratory Improvement Amendments (CLIA) compliance.”

We recommend locating these assurances and scanning them in together with your contracts or referral agreements to keep them all together and organized. If your contract or MOU contains these credentialing and privileging assurances, great! But many times health centers need to look elsewhere for these assurances. Here are some helpful websites that can be used when looking for “nationally-recognized accreditation organizations” or “CLIA compliance”.

Behavioral Health Services

• Commission on Accreditation of Rehabilitation Facilities (CARF®)

Dental Services

• Commission on Dental Accreditation

Hospitals

• The Joint Commission

Laboratory Services

• Lab Corp

• Quest Diagnostics

Pharmaceutical Services

• National Association of Boards of Pharmacy

Public Health Organizations

• Public Health Accreditation Board

Radiology Services

• American College of Radiology

As you work to prepare for your FQHC Operational Site Visit (OSV), whether it be through a mock site visit or your internal efforts, reviewing contracts and referral arrangements early and frequently will help you and your health center move toward HRSA Continuous Compliance. These types of contracts and arrangements often take a great deal of work to edit and volley back and forth between legal counsel teams – so allow plenty of time to craft these documents to be aligned with the HRSA Program Requirements.

Updates:

8/10/2023 - Updated to list the HRSA Site Visit Protocol’s suggestions for documenting assurances.

5/2/2024 - Updated to list helpful resources for finding assurances.

8/27/2024 - Added additional resources to list of resources for finding assurances.