Resources for Credentialed Medical Professionals

Critical Credentialed Medical Provider Resources

The Medical Staff Services Office (MSO) is the administrative backbone of the Baystate Health system. We perform credentialing and privileging for both physicians and advanced practice providers for clinical, professional, and regulatory compliance.

Some of the MSO responsibilities include:

Credentialing for all physicians and Advanced Practice providers for clinical privileges and membership to the medical staff
Enforcing bylaws, rules, and regulations for staff
Managing committees and trustees
Tracking expirable documents including licensing, insurance, and registrations
Joint Commission Medical Staff Standards
Hospital Affiliations
Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE)

Below you’ll find more information related to Baystate Health hospital administration.

MSO Information

Baystate Health Medical Staff Services
280 Chestnut Street
Springfield, MA 01199

MSO Manager

Barbara E. Prats, CPMSM, CPCS
Manager, BH CVO
Notary Public
413-794-1626

For answers to questions and to find contacts for these and other topics, contact the MSO.

Key Contacts & Instructions

MSO Provider Resources

Request an Application

To request an application for medical or associate professional staff privileges and/or membership, email the Medical Staff Office or send a written request to:

Medical Staff Office
280 Chestnut Street, 5th Floor
Springfield, MA 01199

Please include the following contact information in your request:

Name
Practice name (address, city, state, zip, phone and fax numbers)
Date of birth
Email
Privilege type and the associated facility (BMC, BFMC, BNH, BWH )

Application fees are as follows: one hospital: $200.00, two hospitals: $300.00, three hospitals: $400.00 and four hospitals: $500.00

Download the instructions for initial and reappointment application through AppCentral.

Reappointments

Reappointment is the re-verification and/or re-privileging of a provider’s competence . You’ll complete your reappointment every two years and begin the process about four to six months prior to the expiration of your current privileges and/or membership.

When you are getting close to your reappointment time, the MSO will email you a link to start the process.

If you do not complete your reappointment on time, your privileges and/or membership will expire, and you will no longer be able to work or see patients at any Baystate Health facility. When this happens and your privileges lapse, you must complete the initial application process to be appointed to the medical staff and to treat patients at Baystate Health.

NOTE: The Joint Commission standard requires providers to complete the reappointment process every 24 months.

Committees

Medical Staff Executive Committee

The Medical Staff Executive Committee represents and acts on behalf of the medical staff in all matters, except those otherwise provided in the medical staff bylaws and to be consistent with the Joint Commission standards.

The Committee also:

Receives, coordinates, and acts upon appropriate recommendations of the clinical departments, standing and special committees and any reports deemed necessary or appropriate.

Coordinates activities and policies adopted by the medical staff
Recommends to the Board of Trustees medical staff appointments, reappointments, medical staff categories, department assignments, clinical privileges and disciplinary actions while assuring professional and ethical conduct and competent clinical performance of medical staff members
Makes recommendations to the CEO on medico-administrative, medical center management and planning matters

Membership

Wayne Duke, M.D., President – Medical Staff Stuart Anfang, MD Paula Brooks, DNP Anna Clark, M.D. Stephen J. Gallo, MD Rose Ganim, MD Nicolas Jabbour, MD Kathryn A. Jobbins, DO	Christine McKiernan, MD Yelena Mikich, MD Jeffrey Mulhern, MD Robert Eppsteiner, MD Joseph Schmidt, MD Michael E. Swirsky, MD Peter A. Vieira, MD Jacqueline J. Wu, MD

Credentials Committee

The Credentials Committee coordinates the medical staff credentialing process by analyzing applications, making recommendations, and overseeing the maintenance of individual credential files.

The Committee is also responsible for:

Integrating quality and utilization assessments
Monitoring membership
Reviewing and recommending to the Medical Staff Executive Committee approval for delineating clinical privileges for providers
Developing, coordinating, and periodically reviewing recommendations on the procedures and forms that are utilized in the credentialing process and the design and oversight of the credentialing procedures.

Membership

Jeffrey Mulhern, MD – Chair Stuart Anfang, MD Stephen Boos, MD Paula Brooks, CNP Giovanna Crisi, MD Devrim Ersahin, MD James Gebhardt, MD Matthew Gray, MD	James Khoury, MD Peter Koppenheffer, MD Ziad Kutayli, MD Timothy Lepore, MD Oscar Martinez, DO Stanley Strzempko, MD Lori Trask, MD Marcia VanVleet, MD

Pharmacy & Therapeutics Committee

The role of the Pharmacy & Therapeutics Committee is to fulfill medical staff responsibilities and functions relating to pharmacy and therapeutics policies and practices.

Membership

Janivette Alsina, MD
Charles Cahill, MD
Ziv Corber, MD
Daniel Engelman, MD
Patrick Felton, MD
Mihaela Ivancev, MD
Abigail Orenstein, MD

Stephen Ryzewicz, MD
Jennifer Schimmel, MD
Vittal Setru, MD
Scott Siege, MD
Rakesh Talati, MD
Ruben Vaidya, MD
Peter Vieira, MD

Licensure, Insurance & Certification Expiration & Reporting Policy

Policy

Consistent with relevant state, federal law, medical staff bylaws, and to be in regulatory compliance, all practitioners at the time of appointment and continuously thereafter, must have and maintain the current required documents:

Massachusetts (MA) license
MA license renewal application (required by the state of MA)
Federal DEA Certification with a MA address listed on it
MA Controlled Substance Certificate Registration (MCSR C)
Malpractice insurance face sheet (including policy number, dates of coverage, amount of coverage and any exclusions)
Applicable National Certification for Associate Professional Staff
Applicable departmental certification requirement: examples; BLS, ACLS, PALS, NRC, Moderate Sedation.

Failure of a practitioner to provide copies of the above documents may result in suspension.

Purpose

To ensure applicants continuously meet the qualifications for membership to the medical staff and/or associate professional staff without lapse.

Scope

This policy covers all medical staff and associate professional staff members upon initial application for privileges, and continuously thereafter to satisfy the qualifications and requirements of medical staff membership and privileges and as otherwise consistent with the medical staff bylaws.

Procedure

Sixty days prior to the practitioner’s licensure and/or certification expiration, the MSO will send a notification of the pending expiration to the provider’s contact if applicable. If that isn’t available, it will go directly to the provider.
Thirty days prior to the practitioner’s licensure and/or certification expiration, the MSO will send a notification of the pending expiration directly to the provider.
Third and Final Reminder a final reminder will be emailed directly to the provider two weeks prior to the expiration date.

At two-weeks prior to the expiration dates of the required documents, a pending suspension list will be run to identify the practitioner who failed to submit copies of the documentation described above such as State License and/or license application, Federal and state-controlled substances, certificates of malpractice insurance, and other applicable certificate for the job such as ACLS, BLS, PALS, etc.

The MSO will send email notification of the pending suspension to an established core distribution contact list, including the chief/chair of the department and MSO Staff. If the required documentation has not been received by 10 am at the end of the business day on the date of suspension, the MSO will proceed to modify the privilege type relating to the practitioner to suspended (SUM) in the CIS database and the status as (SUS) in the CACTUS database.

If the required documentation has not been received by 10 am on the day the document expires, (on Fridays at 10 am if the document expires on the weekend or if Monday is a holiday), the MSO will suspend the provider’s privileges/membership.