Credentialing, Privileging & Peer Review

Part I Coming March 19

This virtual course covers the essentials of credentialing, privileging, and peer review, including initial and recredentialing processes, HCQIA protections, peer review best practices and negligent credentialing.

Pricing

Members Included*
Nonmembers $499

*This course is included with 2025 ASCA membership. Members must register for the course in order to receive access to it. If you register for the course before your facility has renewed its membership for 2025, you will be charged the nonmember registration rate; refunds will not be provided.

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Agenda

Part I

Credentialing and Privileging: A Comprehensive Overview

This session explores the credentialing and privileging process unique to ASCs, where, in the absence of a dedicated medical staff professionals, administrators often lead these efforts. Key topics include navigating regulatory and accreditation requirements, verifying provider qualifications, and collaborating effectively with medical staff leadership to grant privileges. We will emphasize the importance of incorporating meaningful, objective data into privilege forms to ensure providers are granted privileges based on verified competence, ultimately enhancing patient safety. Additionally, we’ll highlight best practices for maintaining ongoing compliance with accrediting agencies.

AEU Content Area: Human Resources

Headshot of Nyleen Flores Nyleen Flores, BA FMSP CPMSM CPCO CPCS CASC Chief Administrative Officer Lake Oconee Orthopedics

Mastering Initial Credentialing

This session provides an in-depth exploration of the initial credentialing process, including its purpose and key best practices. We will examine the various verification methods for each file element and offer a high-level overview of accreditation requirements for ASCs. We will also discuss the pros and cons of three credentialing approaches: managing the process in-house, outsourcing to a private credentials verification organization (CVO) and outsourcing to an affiliated health system. Finally, we'll review the steps for creating an initial National Practitioner Data Bank (NPDB) account, address potential challenges and delays in the setup process, and discuss the benefits of continuous query enrollment.

AEU Content Area: Human Resources

Headshot of Anne Wynne Anne Wynne, MHA, CPMSM, CPCS System Director, Medical Staff Services Trinity Health
Headshot of Natalie Rose Natalie Rose, MHA Director, Credentials Verification Organization Trinity Health

Fundamentals of Privileging

Privileging is a crucial component of the credentialing process, defining the specific types of procedures each provider is authorized to perform. Ensuring diligence in privileging is essential to maintaining high-quality standards and achieving optimal patient care outcomes at your ASC. Medical staff privileging is frequently cited as an area requiring improvement during a state, accreditation or Medicare survey, which then triggers a deficiency. This session will explore the fundamentals of privileging—what it is, why it is necessary, when it should be conducted and how to establish a comprehensive privileging process. Attendees will gain practical insights and actionable tips for successfully managing both initial and renewal privileging.

AEU Content Area: Human Resources

Headshot of Mary Ryan Mary Ryan, MBA BSN RN CAIP CASC Consultant Amblitel

Peer Review Essentials

This session will dive into the "why” of peer review and offer a thorough discussion of relevant regulatory requirements. We will analyze the various situations in which peer review is used, including medical staff appointments and reappointments, and use case studies to illustrate real-world incidents that necessitated peer review actions. The session will share practical tips and tools needed to address deficiencies as well as strategies for implementing corrective actions; the different categories of corrective action and legal implications of the peer review process will also be discussed. Attendees will leave equipped with outside resources they can use to support effective peer review practices in their own facilities.

AEU Content Area: Human Resources

Headshot of Rena Courtay Rena Courtay, MBA, BSN, RN, CNOR, CASC Vice President of Ambulatory Surgery Trinity Health

Part II

A Step-by-Step Guide to Recredentialing

This session provides a comprehensive guide to the recredentialing process in the ASC setting. Participants will learn how to manage the expiration of initial privileges, the steps involved in recredentialing a provider and how to proceed if a provider chooses not to renew their privileges. We will examine the recredentialing application, timeframe and steps involved in completing the recredentialing process, beginning with assembling documents for the application through reviewing and filing the letter of acceptance.

AEU Content Area: Human Resources

Headshot of Elodia Flores Elodia Flores, BSN, RN Administrator Choice Care Surgery Center

Navigating Peer Review in ASCs: HCQIA, Physician Rights, Protections and Confidentiality

This session aims to provide a comprehensive foundation and overview of peer review laws, covering key aspects such as the Health Care Quality Improvement Act (HCQIA), due process and privilege. We will review the advantages, limitations and critical components of a peer review and reporting process in light of these legal considerations; and discuss the elements involved in effectively operating a peer review and reporting process in an ASC setting. The session will also analyze public policy surrounding peer review and reporting, examining the laws that support these policies and using recent trends to track their evolution. Using case examples, we will identify the pros and cons of peer review to identify potential risks and opportunities. Finally, we will discuss a range of considerations to showcase the potential benefits of implementing an effective peer review program in the ASC setting.

AEU Content Area: Human Resources

Headshot of Eric Plinke Eric Plinke, MBA CPA CASC Partner / Attorney Dinsmore & Shohl

Negligent Credentialing

This session will delve into negligent credentialing, exploring the clinical and legal ramifications for ASCs. We will examine common scenarios where credentialing risks arise and discuss examples of credentialing issues that led to litigation and significant consequences for patient safety and ASC operations. The session will also provide practical, real-world solutions you can use to minimize the risks that negligent credentialing poses to you and your ASC.

AEU Content Area: Human Resources

Headshot of William Miller William Miller, ESQ Partner Higgs, Fletcher & Mack

Select each heading tab below to find out more information.

Continuing Education

To receive credit, you must complete an evaluation for each session through the Education & Events Portal by December 31, 2026. Use the same ID number listed in your registration confirmation email. If you have any questions regarding your customer ID, please contact registration@ascassociation.org.

  • Administrator Education Units (AEUs): This program is approved for up to 7.00 units of AEU credit for the Certified Administrator Surgery Center (CASC)® credential by BASC Provider #3272.
  • Nursing Contact Hours: This program is approved for up to 7.00 nursing contact hours by the California Board of Registered Nursing, Provider #6949.

Disclosure

These presentations may include opinions, advice, statements, materials, data, images, videos, documentation and other information (“Materials”) expressed or shared by presenters. The Materials are for informational purposes only, and the statements, views and opinions expressed at any presentation, or in any Materials, are those solely of the presenter and not of ASCA. Further, ASCA does not endorse or recommend any specific presenter, promoter, company or center, or any views mentioned at any conference or meeting, or in the Materials. Under no circumstances, will ASCA (or its directors, officers, employees or agents) be liable for the accuracy, quality or reliability of any of the presentations or Materials, or any defamatory, offensive or illegal conduct of presenters, including but not limited to intellectual property infringement or any direct, indirect, incidental, special or consequential damages arising from any presentations or Materials.

Cancellation Policy

Registration fees are nonrefundable.

Can’t attend? Someone from your facility can attend in your place. Substitutions can be made free of charge for your initial substitution and $55 for each additional. All requests must be made in writing and sent via email to the ASCA Meetings Department at registration@ascassociation.org.

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