Credentialing & Privileging | 01.21.25
Make Room at the Credentialing Table: Federally Qualified Health Centers Are Here!
By Suzette Ansay, CPCS
Federally Qualified Health Centers (FQHC) play a crucial role in providing healthcare in the United States. Credentialing and privileging programs are an important part of health center operations; MSPs must interpret and navigate requirements to maintain compliance with the Health Resources and Services Administration (HRSA). This article focuses on in-house credentialing and privileging programs: guidance on establishing and documenting your process, HRSA requirements, and insight into HRSA site visits.
What is an FQHC? It’s a community-based outpatient health center that receives federal funding under HRSA. FQHCs focus on patient-directed primary care that serves vulnerable and underserved populations. In addition to primary care specialties, FQHCs integrate pharmacy, behavioral health, substance use disorder, and oral health by providing these services on-site or through delegated agreements with community partners. Additional characteristics are cultural competency, care coordination, service regardless of ability to pay, patient-centered, and nonprofit or public entity status. All patients are welcome and have access to the healthcare services they need when they need them in the community they live in.
Medical services in an FQHC are similar to other facilities. A detailed, documented process for eligible practitioners is vital to operating a compliant credentialing and privileging program. HRSA provides guidance, but the actual process is determined by the health center based on operational and leadership structure.
FQHCs utilize policies and procedures (P&P) to govern their program. MSPs should have an active part in writing and updating the P&P and must ensure that they are tightly followed. Essential elements of a P&P are: HRSA compliance manual language, file structure, credentialing and privileging steps, required documents, primary/secondary source designation, eligible practitioner types, file categorization/review, approval/denial authority and structure, appeals, modification of privileges, reappointment cycle, and temporary privileges. Forms, checklists, or other tools should correspond with and be noted in the P&P.
MSPs must be diligent in record keeping, tracking, and adhering to P&P. Utilizing industry-recognized credentialing systems is highly recommended. Be sure to review your forms, P&P, and practitioner files on an ongoing schedule. Having a system set up for ongoing review makes site visits go much smoother — you should be confident and proud of your program!
HRSA determines primary and secondary source requirements based on practitioner type. At a minimum, license verification, fitness for duty, National Practitioner Data Bank (NPDB), identification, education/training, basic life support (BLS), competency, and immunizations are required. Privileging forms must be on file and detail scope of practice, licensing/education requirements, and privilege assignments. Reappointment is required every two years, even in states allowing three years. Temporary privileges are permitted only when there is a government-declared emergency or on a case-by-case basis approved by HRSA.
Eligible practitioners are where FQHCs really differ from many other facilities. Typically, credentialing and privileging is limited to physicians and other providers. In an FQHC, this is extended to all clinical staff, including physicians, PAs, NPs, dentists, behavioral health, pharmacists, nursing, medical assistants, technicians, and community health workers — anyone who is involved in direct patient care.
Most MSPs are familiar with at least one of the large accrediting agencies. For FQHCs, HRSA provides a similar level of oversight. Site visits are performed every three years by a group of expert reviewers to ensure compliance with the primary areas of focus: administration/governance, clinical, and fiscal. The credentialing and privileging program falls under the clinical area.
During the visit, the reviewer takes a deep dive into the P&P, practitioner files, and contractor agreements (delegated credentialing). They proactively review all P&P, audit practitioner files, and carefully compile sample files for the reviewers that check all the boxes. HRSA releases site visit manuals — read them cover to cover! They provide detailed information so the visit should feel like taking an open book exam. Something to remember — reviewers are not only there to ensure compliance, but to provide technical support. Be open to their advice on best practices. The visit flows better when they feel a collaborative relationship with you. At the end of the day, the goal of HRSA and all of us in FQHCs is to provide the safest and highest quality patient care possible.
MSPs in FQHCs are becoming more prevalent in the medical services field; it’s time to make room at the credentialing table!