At Joint Commission accredited medical facilities a required, standardized credentialing policy is the basis on which appointments to the medical staff, written clinical privileges and other responsibilities are individually assigned to licensed medical and osteopathic physicians, dentists, optometrists, podiatrists and chiropractors. These six professions thus undergo the same credentialing process and standards and are referred to as Medicare Physicians by the Centers for Medicare and Medicaid for billing and other purposes.
Licensed practitioners other than this group of six are credentialed and assigned clinical privileges under separate, differing standards at Joint Commission accredited medical facilities and bill Medicare and Medicaid via different code groups.
This article explains how credentialing and privileging of this “group of six” is done, their three possible levels of privileging (general, specialty and subspecialty practice) and the role of the American Board of Certification in Medical Optometry (ABCMO) in credentialing optometrists practicing at Joint Commission accredited medical facilities.(1)
U.S. Department of Veterans Affairs medical facilities are the largest single employer of optometrists and each VA medical facility is individually Joint Commission accredited. The VA credentialing document for these six prescribing health professions listed above can be found at the end of this article.
Because the great majority of optometrists practice in private, independent offices not part of medical facilities, they are not as conversant with the credentialing process at Joint Commission medical facilities as physician, dental and podiatry colleagues.(2)
Approximately 5% of optometrists practice within Joint Commission accredited federal and state-chartered HMOs, hospitals, clinics and other medical facilities where credentialing and privileging of practitioners follow uniform established policy. While accredited medical facilities require the professional degree and an active state license they, in addition, carefully review each applicant’s post-professional degree training, if any, other pertinent credentials and previous clinical experience and privileges.
At Joint Commission accredited medical facilities, applicant physicians, optometrists, dentists, podiatrists and chiropractors undergo identical scrutiny by credentialing committees and complete identical application forms. The chief purpose of this process is to best assign clinical privileges and responsibilities congruent with each applicant’s global education, training and experience.
A first step in credentialing requires each applicant physician, optometrist, podiatrist, dentist or chiropractor to state whether they are applying as a general practitioner of their licensed profession, a specialist or sub-specialist in an area of their licensed profession.
The three levels of privileges granted at JC accredited medical facilities are:
- General Practitioner: Degree + License appropriate to profession.
- Specialist: 1 above + Specialty Residence + Passage of Specialty Exam + Certification by Specialty Board.
- Sub-specialist: 1 and 2 above + Fellowship sub-specialty Training.
This essay explains the credentialing system at JC accredited medical facilities and the distinctions between credentialing as a general practitioner, specialist or sub-specialist, and the role ABCMO plays in this credentialing process.
The Joint Commission
This national accrediting body, organized some 80 years ago, accredits over 18,000 federal and state-chartered health care organizations that include hospitals, medical centers, HMOs, home care agencies, and health clinics. Approximately 85% of US medical facilities are accredited by the Joint Commission and its accreditation is the “gold standard” and a prerequisite for Medicare-Medicaid participation and billing.
The Joint Commission does not accredit, or hold jurisdiction over, private independent offices. For this reason, private practice optometrists are generally unaware of its credentialing policies unless they apply for privileges at a JC accredited medical facility.
The Joint Commission led in requiring hospital physicians performing more complex procedures and diagnostic tests to have postgraduate specialty residency training and specialty board certification. This phased out the once common practice of permitting general practitioners (Level 1 credentialed) to perform specialty procedures and tests within hospitals and accelerated the growth of specialty residencies and board certification in medical specialties. Later, specialties requiring residency training and certification developed in dentistry, podiatry and optometry in that chronological order.
Private, independent offices not falling under Joint Commission jurisdiction can, and do, offer any procedures falling within the licenses of their providers irrespective of whether these are specialty procedures that require a specialist to provide if done at an accredited medical facility.
Joint Commission Expands Jurisdiction
At inception, Joint Commission policy limited hospital medical staff membership and awarding of written clinical privileges to physicians and dentists. Privileges for other clinicians were then set by that medical staff and varied widely. Osteopathic physicians, podiatrists and optometrists were generally refused medical staff membership and medical privileges. For this reason, osteopaths once had to maintain their own hospitals to obtain hospital privileges but, over time, identical licenses to “practice medicine” became issued to M.D. and D.O. holders and both are considered, by state laws, to be physicians and often practice together at most medical facilities.
In 1986, Joint Commission policy expanded to permit optometrists and podiatrists to be elected members of the medical staff and hold clinical privileges permitted by their state license and the medical facility. Joint Commission policy guidelines now require physicians, dentists, optometrists, podiatrists and chiropractors be credentialed under identical standards. Application for Physicians, Dentists, Podiatrists, Optometrists & Chiropractors – VA Application Form 10-2850 (PDF).
There are now 74 recognized specialties in medicine, osteopathy, dentistry and optometry that require specialty residency training, passage of a specialty written examination and board certification in the specialty. The first medical optometry residency was established by the VA in 1975. By 2005 the National Board of Examiners in Optometry, in cooperation with the National Association of VA Optometrists, began administering a national, standardized specialty examination, Advanced Competence in Medical Optometry (ACM0), and in 2010 ABCMO began offering board certification in the specialty medical optometry.
After 2010, credentialing committees at Joint Commission accredited facilities began credentialing optometrists certified by ABCMO as specialists in medical optometry.
Joint Commission policy governing credentialing of allopathic and osteopathic physicians, dentists, podiatrists, optometrists and chiropractors and the levels of credentials granted them is uniform across accredited medical facilities.
These 6 providers, or “Medicare Physicians” as termed by the U.S. Centers for Medicare and Medicaid, are considered a subgroup of those providers referred to as “Licensed Independent Prescribers”.
Differences between Private Practice and Practice at JC Medical Facilities
In addition to undergoing the same credentialing and privileging process at Joint Commission facilities as physicians, an optometrist is subject to periodic record and peer reviews, professional performance reviews and ongoing (usually biannual) confirmations of licensure and advanced specialty credentials. They must also periodically furnish their self query results from the National Practitioner Data Bank of any adverse actions taken against them as well and continue to meet the licensure renewal requirements placed on private practice optometrists by the state optometry board that issued their license.
Another difference from private practice is that a medical facility optometrist can seek clinical appointment in the general practice of optometry or, if qualified, as a specialist. (Step #2 in VA Form 10-2850). Optometrists who have completed accredited residency training in medical optometry, passed the NBEO examination Advanced Competence in Medical Optometry and hold ABCMO certification become eligible for appointment as a specialist with attendant potential for increased responsibilities and advancement.
The current credentialing system, with its three levels of credentialing for physicians, dentists, optometrists, podiatrists and chiropractors* at Joint Commission accredited medical facilities is uniform across the nation and defined as follows:
- General Practitioner: Hold appropriate professional degree from accredited health profession school and active state license to practice the health profession.
- Specialist: Above, plus completion of accredited specialty residency, passage of national uniform written examination in that specialty and board certification by recognized board of certification for that specialty.
- Sub-specialist: Above plus fellowship training in sub-specialty with certification by specialty board encompassing sub-specialty.
When seeking appointment at a Joint Commission accredited health facility, an ABCMO certified optometrist can be credentialed and privileged as a general practitioner of optometry or a specialist board certified in medical optometry.
Joint Commission policy requires certification of specialists be affirmed on a regular basis, usually every two years, and ABCMO provides this confirmation of certification for specialists in medical optometry as described in Article 22 of the ABCMO Bylaws.
Use of Term Board Certification
Joint Commission accredited medical centers limit use of “board certified” and “specialist” to describe physicians, dentists, optometrists, podiatrists and chiropractors* holding Level 2 credentials.
However, some practitioners with Level 1 credentials state they are “board certified”.
Who is Board Certified?
As the scope of medical care broadened after the 1920’s, hospitals (with support of medical and public health societies) began to limit hospital-based specialty procedures to physicians with residency training in them. The Mayo Clinic and John Hopkins Medical School were early leaders in developing residency training in medical specialties. Today, about 85% of physicians (allopathic, osteopathic) are board certified in recognized medical specialties. By contrast, the first hospital residency program for optometrists began much later, in 1975, at a VA hospital, although today about 20% of optometry graduates elect to enter residency training in a specialty of optometry (the Association of Schools and Colleges of Optometry lists specialty residency types).
While board certification in a specialty is not required for the independent, private practice of the 6 medical professions discussed, most physicians are board certified specialists in order to hold privileges at Joint Commission accredited medical centers.
The same is not the case with dentists, optometrists, podiatrists and chiropractors because the majority of them, to varying degrees, are not affiliated with a Joint Commission medical facility and are in the general practice of their profession. As a result the use of “board certified” is chiefly associated with physicians.
Other “Board Certifications”
A few physicians with Level 1 credentials refer to themselves as “board certified” but have not served an accredited specialty residency nor is their “specialty” recognized by the medical or osteopathic professions. Their postgraduate training may consist of training and seminar sessions in their “specialty” instead of residency training in them. One example is the recognized specialty of plastic surgery vs. the non-recognized specialty of cosmetic surgery.
For some years a number of general practice optometrists have portrayed themselves as “board certified in optometry” which, they may claim, is from having been issued a license to practice optometry or from having passed the examinations required for graduation from optometry school. But a license and passage of those examinations are required of all optometrists to enter practice and they are not equivalent to specialty residency training and passage of a written specialty examination. They, like all other practicing optometrists who have not specialized, hold Level 1 and not Level 2 credentials and credential as general practitioners of optometry.
More recently the American Board of Optometry and the National Board of Examiners in Optometry established board certifications for general practice optometrists that, while, differing in requirements, do not require serving a residency in general practice nor passing a specialty examination and do not claim to be specialty boards. Thus these credentials are voluntary, additional continuing education for general practitioners and are of merit, but are not specialty board certifications as understood by credentialing committees at Joint Commission accredited medical facilities.
Other Level 1 general practice optometry education programs of merit are the annual Optometric Recognition Program of the American Optometric Association (begun in 1986) recognizing completion of annual CME in excess of that required for license renewal and election as a Fellow of the American Academy of Optometry (founded in the 1920’s). About 10% of practicing optometrists are Fellows of the Academy and are entitled to place FAAO after their name.
Role of ABCMO
The American Board of Certification in Medical Optometry is the only recognized specialty board in optometry at this time although additional specialty boards will be established since 20% of optometry graduates enter specialty residencies.
Organized in 2009, ABCMO provides a Level 2 credential that requires completion of an accredited residency emphasizing medical optometry, passage of the national examination Advanced Competence in Medical Optometry administered by the National Board of Examiners in Optometry, practice of the specialty for a minimum of 2-years in an appropriate setting and meeting other specifics listed in the ABCMO Bylaws. It has taken 40 years to establish a process equivalent to those used to train and certify specialists in medicine, dentistry and podiatry. A prime supporter continues to be the U.S. Department of Veterans Affairs, Office of Academic Affiliations which first offered these residencies in order to prepare optometrists for hospital practices.
Since 2010, 470 ABCMO certified optometrists have been credentialed as specialists in medical optometry at federal, Joint Commission accredited medical facilities (VA, DOD, US Public Health and Indian Health Service) and at Joint Commission accredited state-charted medical facilities, among them the Mayo Clinical Health System and Henry Ford Hospital System, or utilized as specialists in medical optometry at private optometry and medical group practices.(3) The majority of them hold faculty status at an affiliated school of optometry or school of medicine, are Fellows of the American Academy of Optometry and members of the American Optometric Association.
(1) At this time chiropractors are credentialed at only Level 1.
(2) Formerly the Joint Commission on the Accreditation of Health Care Organizations.
(3) This represents 1% of licensed optometrists in 2015.
* A physician is defined as one holding a state license to practice medicine and includes allopathic and osteopathic medical providers.