Advanced Credentialing and Privileging Concepts

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Start Time:12:00 AM
End Time:12:00 AM
Contact Information
Additional Information

Provided by MHA Health Institute.
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Date & Location

The event has been rescheduled for:
Tuesday, September 8

Hilton Garden Inn
3300 Vandiver Dr.
Columbia, Mo.

Register on or before Monday, August 24.

The registration fee includes continental breakfast, lunch, refreshments and program materials.

This seminar is being offered at a reduced registration fee to MHA-member hospitals thanks to a generous contribution from the MHA Management Services Corporation. This seminar also is eligible for use of the MHA Health Institute coupon. Note: Coupons were mailed to MHA-member hospital CEOs in December 2019.

Hotel Reservation

Request MHA Health Institute room rate: king deluxe $109 + tax



medical staff services professionals, medical directors, vice presidents of medical affairs, quality improvement professionals, CEOs, and anyone involved with credentialing and privileging functions


This program provides a practical, in-depth review of difficult-to-understand aspects of credentialing, recredentialing and privileging, including evaluating and documenting practitioner competency, dealing with low- and no-volume providers, handling information received “off the record,” engaging and orienting medical staff leaders, avoiding confirmation bias in credentialing decisions, and understanding negligence in credentialing.

Participants will discuss tips for compliance with accreditation and regulatory requirements, and provide sample tools, policies and procedures. The presentation will be reinforced with tabletop exercises and other discussion-based sessions. There will be adequate time to discuss issues and answer questions.


Upon completion of this program, participants will be able to:

  • identify the Centers for Medicare & Medicaid Services’ regulations for credentialing and privileging
  • identify credentialing and privileging requirements of The Joint Commission and Det Norske Veritas (DNV GL Healthcare)
  • develop mechanisms for dealing with low- and no-volume providers
  • distinguish key aspects of training for medical staff leaders
  • discuss appropriate means for documentation of practitioner competency
  • define and utilize critical thinking skills in the credentialing process
  • discuss the concept of negligence in credentialing


8:30 a.m. — Registration/Continental Breakfast

9 a.m. — Welcome and Introductions

9:15 a.m. — CMS, TJC Standards and State Regulations for Credentialing, Recredentialing and Privileging Requirements

10:15 a.m. — Break

10:30 a.m. — Information Received Outside the Credentialing and Peer Review Process

11 a.m. — Documenting Competency

Noon — Lunch (provided)

12:45 p.m. — Strategies for Dealing with Low- and No-Volume Practitioners

1:15 p.m. — Applying Critical Thinking Skills and Avoiding Confirmation Bias

2 p.m. — Engaging and Orientating Medical Staff Leaders

2:30 p.m. — Understanding Negligence in Credentialing

3:45 p.m. — Adjournment


Kathy Matzka, CPMSM, CPCS
Lebanon, Ill.

Kathy Matzka is a speaker, consultant and writer with 30 years of experience in credentialing, privileging and medical staff services. Matzka has authored, co-authored and contributed to nearly two dozen books related to medical staff services. As a highly-regarded industry speaker, she has developed and presented nearly 500 programs for professional associations, hospitals and hospital associations on a wide range of topics, including provider credentialing and privileging, medical staff meeting management, peer review, negligent credentialing, provider competency, and accreditation standards.

Continuing Education

Participants must attend the program in its entirety and complete an evaluation to receive a certificate of completion and continuing education contact hours.

This course has been approved for National Association Medical Staff Services 5 continuing education credits. Accreditation of this educational program in no way implies endorsement or sponsorship by NAMSS.

All Other Participants — A certificate for 5 clock hours of attendance will be provided to each person who attends this program in its entirety.