hugh greeley responds - hcpro · hugh greeley responds: ... dea verification is also included in...

A supplement to HCPro, Inc. publications

Hugh Greeley answers readers’ most pressing credentialing and privileging questions

Hugh GreeleyResponds

Volume 1: Credentialing Concerns

Hugh Greeley Responds: Volume I—Credentialing Concerns2

Dear BOC subscriber,

I hope that you find this compilation of Hugh Greeley’s answers to common credentialing questions help-ful and informative. Greeley has been receiving and answering readers’ questions via the “Ask the Expert”feature on HCPro, Inc.’s Web site credentialinfo.com since its launch in 1998. Over the past four years, myeditorial colleagues and I have accumulated a substantial archive of frequently asked questions (FAQs),part of which is presented in this special report.

More of Greeley’s FAQs appear in a separate special report to accompany the February 2003 issue ofBOC’s sister publication, Medical Staff Briefing. To order a copy of this special report, Hugh GreeleyResponds: Volume II—Medical Staff Concerns, call our Customer Service Department at 800/650-6787.

HCPro, Inc. also offers a series of six e-books containing these and more of Greeley’s FAQs (titled HughGreeley Answers Common Credentialing Questions). Visit www.hcmarketplace.com/Prod.cfm?id=663 formore information.

If you’d like to submit any credentialing, privileging, or other medical staff-related questions to Greeley,go to www.credentialinfo.com/comp/askexpert/askquest.cfm.

Enjoy!

Sincerely,

Rena M. CutchinSenior Managing EditorHCPro, [email protected]

For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, please contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.

Table of contents

Credentialing basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Privileging basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Managed care credentialing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Allied health professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Appointment and reappointment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

Hugh Greeley Responds: Volume I—Credentialing Concerns 3

Primary-source verification

Q: Is verification of liability insurance and DrugEnforcement Agency (DEA) certificates mandato-ry? If it is mandatory, what are the guidelines? Iswritten verification required, or can it be via tele-phone or fax? If it is done by phone, how can Iverify that I actually did the verification?

A: Verifying a physician’s DEA number is indeedrequired by the JCAHO. However, since the DEAwon’t release this information, the applicant mustsupply the hospital with proof of his or her DEAnumber(s) and a copy of his or her DEA certificate.The JCAHO, the American Accreditation Health CareCommission (formerly URAC), and the National Co-mmittee for Quality Assurance (NCQA) consider thisas acceptable primary-source verification.

DEA verification is also included in the AmericanMedical Association (AMA) Physician Masterfile andin National Practitioner Data Bank (NPDB) reports,but unfortunately, the JCAHO does not accept eitherof these databases as primary sources for DEA verifi-cation. As of July 1, 2001, NCQA accepts the AMAPhysician Masterfile as a primary source for DEA sta-tus, but not the NPDB. Some hospitals opt to use theNational Technical Information Service (NTIS), whichcan be costly (for more information on NTIS, go towww.ntis.gov/product/dea-csa.htm).

As for primary-source verification of malpractice in-surance, it is not specifically required by the JCAHO,but it can be used as evidence of an applicant’s abili-ty to perform the privileges he or she requests.

However, it is entirely up to the individual hospital todecide exactly what criteria it will require to demon-strate a physician’s ability to perform his or her privi-leges. Whatever they are, they must be written intothe medical staff bylaws.

Many insurance companies charge a fee for a verifi-cation letter. But despite these costs, many healthcare consultants recommend that hospitals verify in-surance coverage. It’s an excellent risk managementmeasure. But again, it’s not specifically required.

Credentialing basics

Q: Could you please tell me your interpretation ofa “verified” DEA certification?

A: Verifying a physician’s DEA status was, up untilnow, extremely difficult. A physician completing anapplication or a reapplication would indicate his DEAnumber. Most agencies, whether state or federal, wouldroutinely refuse to verify whether a physician main-tained a valid DEA number. Today, however, the NTISwill provide hospitals with mechanisms to verify DEAstatus. Such mechanisms are, however, fairly costly andmust be routinely updated. Certain CVOs routinelysweep available federal data to verify a physician’sDEA status.

In the real world, however, most institutions do notverify a physician’s DEA status. They may make an at-tempt to verify this information by sending a letter toan organization that could verify it.

Q: What would be considered acceptable verifica-tion of malpractice history? Should we be check-ing with the current carrier for any pending ordropped claims? If so, how far back is reasonableto check whether there is more than one carrier?

A: The JCAHO requires hospitals to verify all medicalstaff applicants’ evidence of current clinical compe-tence. This evidence should include “involvement in aprofessional liability action under circumstances speci-fied in the medical staff bylaws, rules and regulations,and policies (MS.5.5.3).”

I recommend that health care organizations check witha physician’s current malpractice insurance carrier(s) forany pending or dropped claims, as well as any suits andsettlements. I also recommend checking as far back as10 years. Please note that the 10-year suggestion is notmandated by the JCAHO or any other accrediting bodyor government agency. It is recommended for thor-ough, high-quality credentialing.

In addition to checking with the insurance carrier(s),organizations should also query the NPDB. Somestates, such as Florida, also make available full detailsof malpractice claims through a state database. If thecases aren’t egregious and the continued on p. 4


Sometimes, it is nearly impossible to obtain informationfrom the “primary source” concerning medical educa-tion and certain residency programs. Additionally, mili-tary service is occasionally difficult to verify due to de-struction of military files during fires, etc. In such cases,a hospital should use standard channels to verifymedical education, training, and internship. Whenthese fail, reliance on the AMA Masterfile is perfectlyappropriate.

Q: It has always been my understanding that ahospital is not in compliance with the JCAHO if itsends a request for a reference letter without pro-viding a copy of the physician applicant’s request-ed privileges. Is this really a JCAHO requirement,or is it simply a courtesy of the requesting facility?

A: The JCAHO does not require hospitals to send acopy of an applicant’s requested privileges whenrequesting a reference letter. It is, however, an excel-lent idea. There is really no way an individual canattest to a physician’s specific qualifications if that indi-vidual does not know which clinical activities thephysician will carry out.

It’s not a difficult or time-consuming step. Simply photo-copy the requested privileges, slip them into the envelopewith the reference request, and forward it to the appropri-ate individual. Most people will take a moment to scanthe privileges in order to provide a focused reference.

Q: On new applications, how far back am I re-quired to check on a physician who states he hadan alcohol problem in 1983? I’m being questionedas to why I need to know about events that hap-pened so long ago.

A: Actually, the answer to this question should be in yourpolicy. In the absence of a policy, it should be your poli-cy to develop a policy. Many medical staffs now identifythe time periods necessary for verification. Verifying mal-practice suits as far back as 1983 is probably not relevantfor most physicians. Verifying health status that far backmay also be irrelevant, particularly if the physician hashad an event-free practice pattern since then.

If a physician discloses that he or she had a problem

information provided by the applicant is consistentwith that of the insurance company, the NPDB, andthe state material, no further investigation is necessary.

Q: We are having difficulty obtaining written veri-fication from our state medical board for licensureon our physicians. The board does have a Web siteand wants us to use it. However, we also wantwritten verification as well as telephone verifica-tion, but the board feels that isn’t necessary. Willwe be in the JCAHO compliance if we use the Website, a secure copy of licensure (which we do), andreceive e-mail and telephone verification?

A. Yes, in general you will be in compliance with theJCAHO if you use a secure Web site organized by thestate licensure department. You do not need a copy ofthe physician’s license because obtaining a copy doesnot in any way ensure that it is, in fact, the physician’strue and accurate license. The e-mail verification youreceived is excellent. You do not need to obtain tele-phone verification.

Remember, the ultimate objective is to assure yourselfthat the physician does maintain a current licenseauthorizing him or her to practice medicine or osteopa-thy. A Web site is an excellent mechanism to use forverifying current licensure. You are not obligated toestablish multiple redundant systems in this area.

Q: In reviewing applications of physicians who havepracticed in their specialty for more than 20 years,how much effort should go into verifying their med-ical school, internship, and residency, especially incases where previous practice sites have closed orreferences have died? Is there a cutoff?

A: The hospital should employ standard proceduresconcerning medical school, internship, and residencyverification. Hospitals should use the AMA PhysicianMasterfile to verify basic education and training forphysicians who have been out of medical school andresidency for a substantial period of time. It is moreimportant for the institution to verify past practicesites and to obtain references from health care profes-sionals who can attest to the applicant’s current clini-cal competence.

Credentialing basics continued from p. 3


with alcohol or substance abuse in 1983, the hospitalmust verify that there had been no relapses for thisphysician in the recent past. There is very little reasonto obtain further information concerning the treatmentfor the alcoholism problem as far back as 1983. It isfar more important to make sure that the physicianis currently not an active alcoholic or substanceabuser.

Q: What is your take on using Web sites for pri-mary-source verification? Our JCAHO mock sur-veyor stated that it is acceptable, as long as thesite is firewall-protected and is maintained bythat state’s medical board or licensing agency.

A: Yes, it is perfectly appropriate for institutions touse Web sites for primary-source verification of infor-mation on a medical staff application. The positionespoused in your question is an accurate reflection ofthe JCAHO’s current policy.

Institutions should, however, recognize that many ofthe questions and requests on applications are presentbecause the institution itself wants the information, notbecause the JCAHO requires it. Information requiredby the institution itself can be verified via any sourcedeemed acceptable to the institution. Information spe-cifically required by the JCAHO (i.e., license, educa-tion, training, and current clinical competence) must beverified via a primary or acceptable secondary source,such as the AMA Physician Masterfile.

Q: I whole-heartedly support the “new creden-tialing standard.” However, our corporate com-pliance officer is insisting that we also performcredit checks on all physicians. I feel like this isgoing too far and crossing way over the line. Isthis a common practice?

A: No, a credit check should not be part of a routinecredentialing background check. Reserve it for high-risk employed physicians.

Q: If a hospital participates in the credentialingprocess, how can it obtain information on the“private out-of-hospital” practice of a physician?Such information may adversely affect the physi-cian’s actual qualifications and the original cre-dentialing approval.

A: The hospital should simply request this informa-tion. This information may include, without limitation,information

• from other facilities in which the physician practices

• from the physician’s own office• from any individuals or organizations that

employ the physician (current and past)• concerning malpractice history• concerning licensure, education, training, and

other general background information

If the information requested is not forthcoming, thehospital can simply require that the physician furnishthe information. Failure to do so within a timely man-ner could result in immediate summary suspensionfrom the staff, voluntary relinquishment of the physi-cian’s privileges until the physician complies with therequest, or voluntary resignation from the staff accord-ing to the staff or hospital bylaws or policy.

Q: Which types of questions are considered to be“out of bounds” when interviewing a medical staffapplicant?

A: Your credentials committee should not ask questionsrelative to the applicant’s age, sex, national origin, sexualorientation, religion, marriage status, or any other topicthat is entirely unrelated to professional competence,professional performance, or ability to relate to others.

You might also review your medical staff bylaws, asthey must contain a provision concerning this issue. Ifthey do not, I recommend that your medical staffbylaws state that neither membership nor clinical privi-leges will be based in any way upon the applicant’sage, sex, national origin, or religion. These are general-ly referred to as nondiscrimination provisions.

Q: Can the medical staff office deny an applicationwithout medical staff involvement based on mal-practice history?

A: No, the medical staff office may not deny any appli-cation. The medical staff office may choose not toprocess an application because of the presence orabsence of certain information. For example, a hospitalcould refuse to process the continued on p. 6


application of a physician who recently had a sub-stantial number of malpractice cases. The presence orabsence of malpractice cases does not necessarilyhave anything to do with the quality of an individualphysician’s practice.

However, a physician who has more malpracticecases during the most recent past is obviously differ-ent from the norm. Place the burden on this applicantto demonstrate that the malpractice actions were notbased on problems with patient care, patient rela-tions, billing practice, etc. before the credentials com-mittee considers the application.

Q: Our medical staff is considering requiringboard certification for medical staff membershipand privileges. Our legal counsel has stated thatthe Medicare and Medicaid Conditions of Par-ticipation (COP) specify that “the governingbody must ensure that under no circumstances isthe accordance of staff membership or profes-sional privileges in the hospital dependent solelyupon certification, fellowship, or membership ina specialty body or society.” Legal counsel hasinterpreted this to mean the COP would be vio-lated if the absence of board certification werethe sole basis for denying medical staff member-ship and privileges.

A: Many hospitals nationwide require board certifica-tion/admissibility as a requirement of medical staffmembership. From your question, it seems that yourlegal counsel is overly conservative. They are accu-rately quoting the Medicare COP, but they are inaccu-rately interpreting it.

Accordance of staff membership means that the gov-erning board cannot place someone on staff simplybecause he or she is certified. The COP are moot onthe issue of denial of medical staff appointment duesolely to the fact that someone is not certified.

There are apparently a number of states in which thestate’s attorney general or the licensure statute is morespecific on this issue than in other states.Unfortunately, your institution should seek the adviceof another health care attorney to resolve this issue.

Q: Is there an accepted average industry cost tocredential a physician? Also, are there any break-downs on initial v, ongoing costs?

A: Yes, estimates in surveys show that the cost ofprocessing an initial application from a new physicianranges anywhere from $480 to more than $1,000. Therange of estimates in surveys depends upon the num-ber of physicians credentialed and the extent of thecredentialing activity.

It’s easy to determine the overall cost of a credentialingprogram within an institution. The director of financecould give a dollar value to the administrative servicesnecessary to support this activity—including rent, utili-ties, equipment, salaries, and benefits—with each ofthese apportioned for all those individuals who partici-pate in some manner in the credentialing process.These individuals would include the MSSP, chief execu-tive officer, vice president of medical affairs, and anyothers in some way involved with the credentialingprocess.

Factor in additional costs in the form of opportunitycosts. These would include the time spent by de-partment chairs, credentials committee members,executive committee members, and board memberson credentialing activities.

Other costs associated with credentialing includeprinting, postage, FedEx, telephone, fees necessaryto obtain relevant information concerning credential-ing, as well as the cost of any CVO.

Once you determine the overall cost of the creden-tialing program, divide that cost by the approximatenumber of credentialing transactions, appointments,or reappointments made during a single year. Theresulting number would be the approximate cost ofcredentialing within your organization.

Applying physicians could pay a fee that covers thecost of processing the application. The reapplicationcosts for physicians are somewhat less than those forinitial application because the institution already pos-sesses considerable information concerning the reap-plying physician.



NPDB/AMA Physician Masterfile

Q: Does the NPDB include a thorough search ofthe Office of Inspector General’s (OIG) sanctionlist to detect providers excluded/sanctioned byCenters of Medicare & Medicaid Services (CMS)? Ifso, can we rely on the NPDB results?

A: The NPDB has included information from the OIG’sList of Excluded Individuals/Entities since April 1997,when Medicaid/Medicare Exclusion Reports (MMERs)against licensed health care practitioners were addedthrough a collective effort of the Health Resources andServices Administration, the OIG, and CMS. The NPDBcontains MMERs from February 4, 1981, to the present.To access the sanctions list directly, go to the OIG’s Website, www.dhhs.gov/oig/cums an/index.htm.

Q: When you query the NPDB, you can get a reportof sanctions and restrictions. Does it also includedebarment report information?

A: For information concerning the contents of the NPDB,contact the databank. The databank has information con-cerning settlements paid on behalf of a practitioner in amalpractice case, disciplinary actions taken by legitimatepeer review organizations, licensure actions taken by var-ious states or other governmental units, as well as certainother actions taken by the federal government.

The JCAHO does not specify how much weight shouldbe given to NPDB reports. The database was not createdto replace traditional means of credentialing but to sup-plement them. It should serve as another resource thathospitals, state-licensing boards, and other health careentities can use to conduct a thorough check on practi-tioner qualifications. Reports should be evaluated ratherthan taken at face value, and you should provide practi-tioners with the opportunity to furnish explanations.

Q: Is the AMA Physician Masterfile considered aprimary source?

A: The NCQA recognizes the AMA Physician Masterfile(now called the AMA Physician Profiles) as a primarysource to verify medical education, residency training,specialty board certification, DEA registration status,and Medicare/Medicaid sanctions. The AmericanAccreditation Health Care Commission, Inc. (formerly

called URAC), also considers the AMA PhysicianMasterfile a primary source of information for verifyinglicensure, medical education, residency training, boardcertification, DEA registration status, and state and fed-eral disciplinary sanctions.

In the fall of 1995, the AMA established to the JCAHO’ssatisfaction that it was prepared to meet all the JCAHOrequirements for CVOs. As a result, the JCAHO official-ly recognized the AMA Physician Masterfile as a “desig-nated equivalent source . . . [of] specific items . . .identical to the information at the primary source.”

The significance of this designation is that organizationscan regard information from the AMA PhysicianMasterfile as just as authoritative as informationobtained directly from primary sources. Please note,however, that the JCAHO currently regards theMasterfile as an equivalent source only for two specificitems: medical school graduation and completion ofresidency. Although the Masterfile contains far moreinformation about each physician than the items listed,the JCAHO does not permit use of that information forprimary-source verification.

Q: I recently heard that the JCAHO is not accept-ing the AMA Physician Masterfile as primary-source verification of medical school completionif it is a foreign medical school. Do you knowwhether this is correct?

A: Ideally, hospitals should verify the credentials of for-eign medical graduates (now often called internationalmedical graduates) in exactly the same way as theyverify the credentials of graduates of U.S. medicalschools. In the past, some overseas sources were notas responsive to verification requests. Therefore, in thepast, the JCAHO allowed hospitals to contact reliablesecondary sources—agencies that collect informationfrom primary sources—when the hospitals coulddemonstrate significant but unsuccessful attempts toobtain primary-source verification.

For example, a hospital had to be able to present acopy of an unanswered letter to a foreign residencyprogram as documentation that it tried to obtain pri-mary-source verification. Then the hospital couldobtain verification from the AMA Physician Masterfileor the Educational Commission for continued on p. 8



Foreign Medical Graduates (ECFMG).

However, the JCAHO’s position regarding the ver-ification of overseas medical school graduation haschanged. The JCAHO now considers the possessionof an ECFMG certificate as primary-source evidence ofgraduation from medical school (an applicant’sECFMG certificate must be verified with the ECFMG).There is no change in regard to verification of over-seas graduate training—residencies and fellowships—because the ECFMG does not deal with this at all.

The AMA Physician Masterfile usually begins record-ing data on foreign medical graduates upon theirentrance into medical residency training programsapproved by the Accreditation Council for GraduateMedical Education. It receives background informationon foreign medical graduates from the ECFMG andalso receives information from other organizations asthe training and careers of these graduates develop.

I have not heard of any instances in which a JCAHOsurveyor has not accepted the AMA Masterfile profileas an appropriate means for verifying a practitioner’scompletion of a foreign medical school. The AMArelies on ECFMG information for verification of for-eign medical school graduation, and its literature indi-cates that this information may be relied upon as pri-mary-source information.

Q: Does the JCAHO recognize the AmericanBoard of Medical Specialties (ABMS) as primary-source verification for medical school or gradu-ate medical training, or is the AMA PhysicianMasterfile the only other alternative primarysource other than the schools?

A: Currently, the JCAHO does not recognize certifica-tion through the ABMS as primary-source verificationfor medical school or postgraduate education andtraining. The NCQA will recognize board certificationas evidence that a physician has completed medicalschool and appropriate residency training.

It must be pointed out that certification by the ABMSdoes not, in and of itself, guarantee that a physiciancompleted an approved residency program. There are

many physicians certified in the United States whowere certified through a “grandfathering” clause thatdid not require completion of an approved residency.It is highly unlikely, however, that a physician certifiedby the ABMS would not have completed medicalschool. Therefore, it seems reasonable that the JCAHOshould use board certification as evidence of comple-tion of medical school.

There are, of course, legitimate reasons why theJCAHO requires independent verification of medicalschool, residency training, and board status. Thesethree checkpoints in a physician’s practice career alloworganizations to determine whether they are dealingwith an “imposter” physician. Unfortunately, such indi-viduals do crop up from time to time and only careful,vigorous multipoint verification of education, training,experience, etc. is likely to identify such imposters.

Q: As part of the credentialing process, is thereany requirement to obtain physician profiles fromthe AMA? If you do obtain a profile, do you stillneed to send out letters to the medical school veri-fying that physician’s training?

A: Currently, there is no requirement to obtain the physi-cian profiles from the AMA. I do, however, recommendthat all facilities consider making the AMA PhysicianMasterfile a part of their routine credentialing activities.This information can be extremely useful to credentialscommittees as they process applications from physicians.

If an institution does receive the AMA PhysicianMasterfile printout for an individual physician, it isn’tnecessary to reverify the physician’s completion ofmedical school or the physician’s completion of anapproved residency-training program. The AMA infor-mation on these two issues is verified from the primarysource, and hospitals may rely upon it as though it is aprimary source. However, you still must obtain infor-mation concerning current clinical competence from aresidency director if the applicant recently graduatedfrom a residency program. If the applicant has beenout of a residency program for two or three years, theresidency director’s attestation of current clinical com-petence is not as useful as that of a physician in amore recent practice site.


Privileging basics

Specific privileging criteria

Q: I am trying to develop a policy on how to delin-eate privileges to practitioners who function in acapacity for which there may be no applicablespecialty board. Specifically, is there a board forpediatric developmental delay? If not, what sort ofeducation, training, etc. should a practitioner havein order to hold privileges in this field?

A: No, there is no specialty board for pediatric devel-opmental delay.

It is up to your credentials committee to carefullydefine the criteria that practitioners must meet foracquiring clinical privileges in pediatric developmentaldelay. The criteria might, in this instance, look like thefollowing:

Education: MD or DO• Completion of an approved residency program in

pediatrics leading to admissibility or certification• Documented experience in successfully dealing

with patients with developmental delay

Q: Our small rural hospital plans to build andopen an ambulatory surgery center in the nearfuture. Does this mean we will need to developspecific credentialing and privileging proceduresfor the practitioners who will work in the center,or should we use the same methods as we do atour hospital?

A: If the ambulatory surgery center will operate as adivision of your hospital, it is not necessary for you todevelop further privileging procedures for practitionerswishing to perform surgery there. You will, however,have to make sure that your current privileging system(which perhaps authorizes practitioners via a “privileg-ing list”) accurately reflects the procedures and treat-ments your surgery center will offer. If not, it willrequire some minor amending.

If, however, the ambulatory surgicenter will operate asa separate legal entity (e.g., a joint venture), it will be

necessary for that entity to develop its own credential-ing and privileging policies and procedures.

Q: How do you credential physicians whose pri-mary specialty is research (PhD)? These physi-cians do not have licenses, DEA numbers, or mal-practice insurance. They come to the facility andresearch different cases and are considered con-sultants. Is it necessary to privilege them?

A: Because this type of physician will not engage inclinical practice, it is not necessary to grant them clinicalprivileges. If your institution includes these physicians asmembers of its medical staff, you must recognize thatthey may not, in many instances, meet your member-ship criteria. Very often, medical staff bylaws requirephysicians to hold DEA certificates and malpracticeinsurance policies to qualify for medical staff appoint-ment. It is far more reasonable for your institution todetermine whether these individuals are, in fact, goodresearchers. If they are, either hire them or appointthem specifically to conduct research. Do not grantthem clinical privileges, as they will not engage directlyin clinical practice.

Q: What documentation should we request from afamily practitioner who wants to perform emer-gency C-sections without obstetric surgical back-up? The physician has submitted some documen-tation of his experience in this area, but howmuch is enough? We’ve never processed this typeof request before.

A: The best way to tackle a privileging issue for whichyou have no policy is to develop a policy. The requestitself would be tabled while the credentials committeeand MEC review the issue of C-section privileges andrecommend an objective policy for consideration bythe board. Such a policy should include the minimumeducation, training, and experience required by theinstitution prior to granting C-section privileges to anypractitioner.

Q: Generally speaking, obstetricians (OBs) are privi-leged based on the procedures continued on p. 10


they perform. Is there any guidance or precedencefor adding a statement to the privileges of OBsregarding “caring for general medical problems considered non-life-threatening with appropriateconsultation”? Or are the primary care skills theyacquire during residency training generic enoughthat any licensed OB can do them without specify-ing them in a privileging document?

A: This question relates to the development of a coreset of privileges for individuals trained in obstetrics.Traditionally, OBs have been granted clinical privilegesin two categories:

1. To admit, workup, diagnose, and manage pa-tients presenting with illnesses or injuries of thefemale reproductive system

2. To provide all services related to pre-pregnancy,pregnancy, delivery, and post-delivery issues

It would be reasonable for a medical staff to furtherdefine the clinical privileges of OBs to provide generalmedical care to women if it believed basic OB trainingand experience encompassed this area.

The clinical privileges should be written to avoid anyconfusion about what a practitioner may or may notdo. If an OB has privileges restricted to treating illness-es and injuries of the female reproductive system andperforming deliveries, etc., there would be confusion ifan OB attempted to provide definitive care to a femalepatient with congestive heart failure. A “poor outcome”in doing so might cause concerns about whether theOB was practicing outside of his or her “scope” ofprivileges.

Q: An urologist at our hospital has applied forprivileges in lithotripsy. Where would I find infor-mation to help me determine how many lithotrip-sy procedures he should have performed in thepast to demonstrate competence. I do send a copyof his requested privileges to all current and for-mer hospitals/Residency Directors. Is there aguideline to how many procedures a physicianneeds to have performed?

A: To determine appropriate qualification criteria for

requesting lithotripsy privileges, your institution shouldreview information provided by your existing urologistsabout performing this particular procedure. It shouldalso collect any data available from third parties suchas medical/surgical specialty boards, colleges, and/oracademies.

Please note that absolutely no “magic” number of pro-cedures exists for competence in the area of lithotripsy.It is undoubtedly true that many urologists couldobtain competence in this procedure after performingonly a few of them. Other physicians may requiregreater numbers in order to achieve competence. It iscritical to understand that a physician’s qualification forclinical privileges doesn’t depend so much on numbersof previous procedures performed but on whether hisor her experience was in the direct or indirect treat-ment of the illness necessitating lithotripsy, overallexperience in treating patients with urological condi-tions, completion of approved postgraduate training,and successful completion of medical school.

A physician who has performed many procedureswithout having undergone appropriate postgraduatetraining would not, in most institutions, qualify for clin-ical privileges. Along the same lines, a physician whohas completed an approved postgraduate training pro-gram would not qualify to perform many procedures ifhe or she had not performed them during the residen-cy or within the previous two to three years. Competenceis a function of education, training, and successfulexperience.

Q: Are facilities out of compliance with JCAHOstandards if they send out requests for letters ofrecommendation without including a list of theprivileges sought by the applicant?

A: There is no requirement that a copy of the request-ed privileges must be sent out with requests for profes-sional references. It is, however, an excellent idea.There is really no way an individual can provide anadequate reference about an applicant’s qualifications ifhe or she does not know which clinical activities theapplicant will engage in.

Many individuals (credentialing consultants, surveyors,

Privileging basics continued from p. 9


and even health care attorneys) recommend this prac-tice. It is quite easy to photocopy the requested privi-leges, slip them into the envelope with the referencerequest, and forward them to the appropriate profes-sionals. Most will, in my experience, take a moment toscan the privileges and provide an appropriate refer-ence letter.

Q: If, within the department of medicine, the divi-sion of cardiology adopts and passes its own privi-leging criteria, must they pass through the creden-tials committee before the department chair canuse them? What would regulatory agencies sayabout privileging criteria that’s used without thecredentials committee’s approval?

A: Make it clear to everyone in your organization thatindividual departments or sections are not authorizedto create their own privileging criteria. They may par-ticipate in establishing criteria by submitting recom-mendations to the MEC for ultimate approval by thegoverning board. If departments did create their owncriteria and used them to exclude other practitioners,the antitrust implication could be considerable. Such anact could, in fact, constitute a per se violation of theClayton and Sherman Antitrust Acts.

Privileging criteria should be drafted by relevant spe-cialty groups, departments, or sections and submittedto a committee authorized by the MEC to receive andconsider such criteria (e.g., the credentials committee).The committee then should submit the criteria to theMEC for its consideration. If the MEC finds no problemor controversy with the criteria, it should forward itsrecommendations to the board for final approval.

Pain management

Q: Are there any specific criteria for physiciansrequesting privileges in pain management? Shouldthey submit documentation of any special training?Should their credentialing process be any differentfrom any other members of the medical staff?

A: The credentialing process for a physician interestedin pain management privileges need not be any differ-ent from that of any other medical staff member. Thespecific privileging criteria should be specific to thepain management discipline, as opposed to bypass sur-

gery, for example. Of course, physicians interested inpain management privileges should be required todemonstrate that they have training in pain manage-ment techniques.

Such training could have taken place in a formallyrecognized residency or training program, or in post-graduate continuing medical education courses taughtunder the auspices of a recognized university or train-ing center.

Criteria for pain management privileges should alwaysinclude the minimum amount of education, training,and relevant experience the applicant must possess.You should also require peer references specific topain management.

Q: We have a physician practicing pain manage-ment. Questions have been asked about his skillswith cervical discograms, including two cases ofhigh spinals following these procedures. He isrequired to have a proctor for his next six cases.His proctor (the only one who will serve out ofthe few available) refuses to proctor him on anymore cervical discograms. What can we do?

A: Under these circumstances, the MEC or officers ofthe medical staff must consider the issue and determinewhether they believe it is safe for this individual tocontinue to perform cervical discograms without con-current monitoring. It appears that the hospital isunable to provide an individual to review his work onan ongoing basis.

The MEC/hospital has a number of perfectly legitimatealternatives to choose from, including the following:

1. The institution could “command” that members ofits staff participate in proctoring as a responsibilityof medical staff appointment. I do not suggest thatthe institution select this option, as it will undoubt-edly prove unpopular and ineffective. Nor do I rec-ommend that physicians be obligated to “proctor”an individual if they have determined, for reasonsknown to them, that they’re unable to do so.

2. The institution could hire an individual to proctorthis physician for a specified continued on p. 12


number of cases. The proctoring physician wouldbe compensated for his or her observation activi-ties. Under these circumstances, the individualwould not have to be made a member of the med-ical staff, as he or she would not engage in patientcare but would observe patient care and render areport to the MEC or the appropriate departmentchair for consideration. Such individuals are avail-able, and if the institution should decide to assumethe burden for such proctoring, this would be anacceptable solution.

3. The institution could require that the physicianobtain the services of another physician to eitherassist or monitor his or her work for a determinedperiod of time or a determined number of cases.The entire burden for such proctoring could beplaced on the physician, at his or her expense.This would be as a condition of continuing theclinical privilege for cervical discography or painmanagement.

4. The institution could secure the services of a quali-fied outside expert to review all of this individual’scervical discograms for the past “X” months andrender an objective written report concerning theappropriateness of the clinical work documented inthe record. Such a report could be augmentedthrough on-site or off-site interviews of selectedmedical staff members in a position to provideinformation deemed useful in the external reviewprocess.

It is of utmost importance to keep our eye on the tar-get in regard to this question. Clearly, the institutionand the medical staff have questions concerning thequality of services being provided by this physician.

If the institution cannot determine a mechanism thatwill result in the safe provision of these services, theinstitution should take steps that serve to protect thepatient.

Medical staffs very often select proctoring or directobservation of clinical work when they are interested

in obtaining more information concerning a physician’scurrent clinical competence. If the medical staff hasdetermined that a physician’s competence is seriouslyin question, or if they themselves would not permit aphysician to engage in this practice on them or on amember of their family, then the institution should rec-ognize that proctoring is an ill-advised approach.

A better approach would be to require that, for a peri-od of time, this physician have an assistant for the per-formance of all of these procedures.

The presence of an assistant serves to more directlyprotect the patient, as the assistant will unlikely engagein patient care activities that are potentially injurious.The responsibility for obtaining the assistant would fallclearly on the physician as a condition for exercisinghis or her privileges on a continuing basis.

Q: If an anesthesiologist wants to perform painmanagement procedures such as placement ofepidural spinal cord stimulators and placement ofintrathecal catheters, what type of additional train-ing would he or she need?

A: A physician who wishes to engage in the activitiesdefined above should have residency-type traininginvolving the specific procedures in question.

He or she should also have clinical experience in theseareas, either from the residency program or from post-residency experience. If the residency training occurredsome time ago, the individual should demonstraterecent clinical experience in performing the proceduresoutlined in this question.

Require such a practitioner to obtain references fromknowledgeable individuals who can and will attest tohis or her current clinical competence in this area.

Absent formal residency training (or, post-residencytraining acceptable to the credentials committee) andevidence of recent clinical experience in addition toreferences from knowledgeable individuals, the practi-tioner should not be permitted to apply for theseprivileges.

Privileging basics continued from p. 11


Managed care credentialing

Primary-source verification and other credentialingbasics

Q: I am employed by an NCQA-certified CVO andhave a question about hospital verifications. It’snot clear in the NCQA language whether it is okayto receive verbal verification from hospitals. Ofcourse, when I say “verbal” I mean speaking withsomeone in the medical staff office and notatingthat person’s name, the date and time of the call,and exactly what that person told me. What isyour opinion?

A: Generally, an organization may rely on a contempo-raneous note as confirmation of information used inthe credentialing process. You state that when youspeak with someone in another medical staff office,you note that individual’s name, the date, time of thecall, and exactly what was relayed to you. This noteshould serve to provide the information necessary tothe credentials committee without requiring the individ-ual to put it in writing.

If you receive negative information in this manner, Isuggest that you immediately turn that information intoa specific questionnaire and send it, with an appropri-ately executed release, to the individual who initiallyprovided you with the negative information.

In general, when an institution moves to core privi-leges, it is not necessary to “back up” core privilegeswith an extensive list defining what is in the core in allspecialties. It would, however, be necessary to back upa core set of privileges with a more detailed list ofareas where procedures are performed. Hospital staffmust have a mechanism permitting them to monitorwhether or not a physician is scheduling proceduresaccording to his or her clinical privileges. Such a listneed not be made part and parcel of the core. A listdefining (for nursing or operating room staff) what isin the core can simply be provided to them in a policymanual.

I realize that this seems to negate the value of the coreprivileging process. Actually, it doesn’t. Moving to acore permits individual physicians to request privileges

in a more rational manner. It is the institution’s respon-sibility to understand what privileges generally fallwithin the core and make such information available tostaff for monitoring a physician’s adherence to his orher clinical privileges.

It absolutely is not necessary to back up core privilegesin emergency medicine with a list of all emergenciesthat may occur or all procedures that could be per-formed in that area.

Q: We are an NCQA- and URAC-accredited man-aged care organization (MCO), responsible for cre-dentialing/recredentialing hospitals, home healthagencies, skilled nursing facilities, nursing homesand free-standing surgical centers. Do you haveany information or recommendations on the bestpractice for credentialing these entities? Do yourecommend that the information we gather be pri-mary-source verified?

A: Consider amending your credentials policies andprocedures to incorporate the “new credentialing stan-dard.” (For more information about the “new creden-tialing standard”, visit www.credentialinfo.com.) Thereis very little question that hospitals and other organiza-tions should strive for the very best background infor-mation concerning all physicians they permit to prac-tice within their facility. It is also my belief that the cur-rent NCQA and JCAHO standards, while representingexcellent initial benchmarks, do not quite go farenough in today’s complex environment.

Researching a physician’s criminal past, drunken driv-ing record, federal warrants, and arrests records, aswell as obtaining well-drafted professional referencesconcerning clinical competence and overall profession-alism, is essential if an institution is interested in care-fully evaluating all potential applicants.

Q: We credential MDs, DOs, and DDSs. What otherproviders should be scrutinized at this level (i.e.,physician assistants, nurse practitioners, or socialworkers)?

A: The NCQA requires that all continued on p. 14


individuals listed in an MCO’s provider manual must besubject to a credentialing process. The NCQA’srequired credentialing process is not synonymous withthe credentialing process in an acute care hospital. TheNCQA requires the verification and evaluation of infor-mation concerning the provider’s background, education, training, license, claims history, etc. prior tolisting a physician in the provider manual.

If an MCO contracts with a physician who employsnurse practitioners (NPs) within his practice, but theNPs will not be listed in the provider manual, the MCOdoes not have to specifically evaluate the qualificationsand duties of the NPs. The contract that the MCOenters into with the physician should cover the physi-cian and his or her employees working under his orher direct supervision.

Q: The NCQA requires that facilities recredentialevery 36 months. If I send out reappointmentapplications, then send out a second applicationand still don’t get a response, how would I be ableto meet this standard? Does documenting theattempts suffice?

A: No, the NCQA clearly requires that physiciansappointed to a managed care panel be recredentialedevery 36 months. If a physician fails to complete theappropriate reapplication forms, his or her appoint-ment to the panel simply expires at the end of the ini-tial 36-month appointment period. The physician is nolonger on the panel and therefore would no longer besubject to the 36-month recredentialing requirement.

If the physician wants to remain on the panel, it is hisor her responsibility to complete the forms submittedby the MCO. The credentialing staff that diligentlysends out reapplication forms well in advance and fol-lows up on those not returned with a second request(and in some instances even a third or fourth request)should not confuse the attempt to encourage physi-cians to reapply with the requirement that physiciansappointed to an MCO panel be recredentialed andreevaluated every 36 months.

This issue is exactly the same within an accreditedacute care hospital. Nearly all sets of medical staff

bylaws as well as relevant JCAHO and AmericanOsteopathic Association standards require that appoint-ments be no longer than 24 months. If a physician failsto complete the appropriate reapplication forms, thephysician’s reappointment should expire at its normalexpiration date. I do not, in any instance, recommendthat an institution maintain a physician on its medicalstaff if that physician has not requested reappointmentto the staff.

A distinction should be made here between the physi-cian who reapplies within an appropriate time periodand the physician who fails to complete appropriatereapplication forms. A reapplication that is legitimatelydelayed in processing could result in the granting of atemporary appointment to the staff (reappointment)and a temporary grant of privileges pending comple-tion of the entire reapplication process. The physicianwho reapplies is simply no longer associated with thefacility. Letters accompanying reapplication shouldclearly establish the effect of noncompliance with thereapplication process.

Q: We are a physician-hospital organization thatperforms credentialing/recredentialing. If youhave an automated system in the physician’soffice during normal business hours, does theNCQA require that the system provide you with alive person instead of voice mail?

A: No, the NCQA does not require that you provide alive person.

Q: Regarding physician credentialing standards,will you please define “gap in work history”?NCQA standards address gaps of more than sixmonths. My credentialing department processesphysicians to meet both JCAHO and NCQA stan-dards (for the hospital and the independent prac-tice association), and I want to develop a blanketpolicy that will cover gaps.

A: I believe that when a gap appears on an applicationor reapplication of longer than one month, the institu-tion should attempt to verify the activities of the physi-cian during that time period. I don’t find compellinglogic with the NCQA’s requirement that the gap be

Managed care continued from p. 13


defined as six months. A physician with a work historygap of only one month could have, during that month,participated in a drug rehabilitation program, servedtime in jail, or been sanctioned from the Medicare pro-gram. You can require a physician to provide a writtenand verifiable description of his or her activities duringa reasonably short period of time.

Q: Please answer the following questions:

1. Can we request primary verification from thevarious data sources prior to providers returningthe credentialing or recredentialing applications?

2. Is documentation accepted by the NCQA if thedocuments are no more than 180 days old atthe time of committee review and approval?

A: A “double yes” to these questions. It’s appropriate foran organization to verify various pieces of informationprior to the receipt of a recredentialing application. Aslong as information is no more than 180 days old priorto credentials committee review, the early verification ofsuch information will be acceptable to the NCQA.

Q: Is it essential to solicit information from peers?We do not employ physicians; we contract withthem.

A: In general, MCOs should solicit information frompeers prior to entering into an employment contractwith physicians. Information concerning licensure, edu-cation, training, past practice, and reputation in thehealth care community, to name a few factors, is cer-tainly useful. However, this information alone does notindicate current clinical competence. Only informationreceived from individuals within the general clinical dis-cipline verifies the practitioner’s current clinical ability.

A peer for an MD is an MD (not necessarily someonein the same specialty). A DPM would be a peer to aDPM, a nurse-midwife would be a peer to a nurse-mid-wife, and so on. MCOs should not limit themselves tothe acquisition of any specific sets of information con-cerning the qualifications and competence of practi-tioners wishing to join the MCO’s panel.

MCOs should use policies that provide them with agreat deal of flexibility, permitting them to acquire in-formation not only from peers but also from other indi-

viduals who are qualified to comment on a practition-er’s abilities.

Q: Should all referrals outside the health mainte-nance (HMO) network be credentialed? If so, how do you do this?

A: Usually, an MCO should know to whom its patientsare being referred. The “credentialing” of these individu-als should establish that the MCO knew that the referralwas made and knew the qualifications of the individualto whom the referral was being made.

Because not all individuals to whom a patient might bereferred will be listed in the provider manual, it is tech-nically not necessary (under the NCQA standards) thatsuch individuals be “credentialed” through the MCO’scredentialing process. The MCO should know to whomits patients are being sent, for what purposes, andunder what financial arrangements.

The MCO has an independent duty to credential thosepractitioners who contract with it. (Harrell v. TotalHealth care, Inc., 781 5,w.2d 58 Mo. 1989. See alsoSchleier v. Kaiser Foundation Health Plan, 876 f.2d.174C D.C. App. 1989, where the involvement of a con-sulting physician with no contractual relationship to theHMO was sufficient for a jury to render a verdict of$825,000 against the plan.)

Q: Are diagnostic and treatment centers requiredto query the NPDB? The NPDB states in order toquery you must have a formalized peer reviewprocess in place. Can you define what is consid-ered a formalized peer review process?

A: Organizations granting clinical privileges and/ormedical staff membership are strongly encouraged tocontact the NPDB prior to the granting of such clinicalprivileges. If you are unclear as to whether your organ-ization would qualify as a formalized peer review enti-ty, you should contact the NPDB and obtain a list of itsprerequisites.

Generally, however, any organization with a formalizedor documented peer review program and a credential-ing program resulting in the granting of clinical privi-leges would be considered a peer review entity forpurposes of accessing the NPDB. continued on p. 16


More important is that the NPDB may have informationthat would be useful to the operation of diagnostic/other treatment centers.

The databank information could certainly be useful, ascould the information that is readily obtainable fromthe American Medical Association Department ofCredentialing Support Products (312/464-5310).

Q: How important is it to have copies of DEA cer-tificates for practitioners who practice in morethan one state? We are a network credentialingorganization and have associated facilities in twostates. Do we need copies of DEA certificates forboth? The DEA wouldn’t sanction a license in onlyone state, would it?

A: Hospitals and medical centers permitting physiciansto order certain types of pharmaceuticals must ascertainthat the physician has a valid DEA certificate. If theinstitution has physicians on its staff who practice inmore than one state, it’s sufficient for the institution toverify DEA status one time.

You do not need multiple copies of the DEA certificate.If the state issues its own certificate permitting physi-cians to order certain types of medications, then themedical center or hospital must verify the physician’spossession of the required certificate in any and allstates in which the physician will be prescribing suchmedications. The last component of this question isanswered as follows: The DEA will generally not “sanc-tion” a physician’s certificate in only one state.

Q: We are a medical staff office (MSO) for a singlespecialty reaching several states. During employ-ment screening, can we query the NPDB and veri-fy licensure without a signed release? We don’t yethave these two items incorporated into our hiringpolicies for physicians because credentialing isnew to our organization. Should we incorporatethis into our policies or have a separate policy for

Managed care continued from p. 15

physicians?

A: The answer to this question is complex, and theinstitution’s final policy should be reviewed by a healthcare legal expert.

Usually, MSOs are not considered qualified peer reviewentities for purposes of the Health care Quality Im-provement Act of 1986. As such, they would not beauthorized to query (on their behalf) the NPDB. If anMSO has been designated as an agent for an authorizedpeer review entity and is querying on behalf of that enti-ty, it would certainly be able to make databank queries.

A physician should be required to sign a specificrelease authorizing a credentials agency to verify his orher past education, training, experience, and clinicalcompetence. Such authorization also should apply toany other query made to evaluate the physician’s pastperformance. This would include databank requests,malpractice verification queries, disciplinary actionqueries, and all other types of information deemed rel-evant in the credentialing process.

Any MSO policy concerning the mechanisms used toverify the background, education, training, experience,and current clinical competence of a physician shouldbe well documented. Whether this policy is part of thenormal policies concerning employment screening or aseparate policy applying physician employees is up tothe individual organization.

However, we generally recommend that organizationsparticipating in the phase one or phase two compo-nents of the credentialing activity have thoroughlydetailed policies and procedures addressing the mecha-nisms used to collect, verify, store, disseminate, andanalyze information concerning physicians. This wouldapply whether these physicians would be employeesof the organization, or whether the organization ismerely performing this activity on behalf of a hospital,multispecialty group practice, or other organization.


Allied health professionals

Clinical privileges/temporary privileges

Q: Should health care organizations delineate clin-ical privileges to all allied health professionals(AHPs)? How detailed should the delineation be? Isthe supervising or employing physician responsi-ble for determining what dependent AHPs do?

A: The hospital should outline a scope of practice forall of its practicing AHPs. For some AHPs, that may bethe clinical privileges that they have been granted. Forothers, it may be a job description. The descriptionshould be specific enough to establish clearly the limitsof the practitioner’s practice within the hospital.

Although a supervising or employing physician maydetermine what an AHP can do in any given clinicalsituation, the scope of practice for a particular type ofAHP is entirely up to the individual hospital. So an em-ploying physician may not order his or her physicianassistant to perform a procedure that the hospital ex-cludes from a particular scope of practice.

The hospital’s policies and procedures should state thatthe supervising/employing physician accepts responsi-bility for making sure his or her AHPs are not exceed-ing the hospital-approved scope of practice.

Q: How long should you grant temporary privi-leges to an AHP? I have a note that states 90 daysis the time period and that you must never give anextension.

A: A better question is, “Why grant temporary privi-leges to an AHP?” If you do, your policy should indi-cate the period during which temporary privileges maybe exercised. Hospitals often establish 90 days as theperiod during which temporary privileges may be exer-cised. Your hospital is free to define the time period.It’s more important to consider the various pressuresforcing you to grant temporary privileges to AHPs.

Q: Which AHPs should be granted clinical privi-leges, and which should practice according to a

scope of practice or job description?

A: That is a decision each hospital must make. Thereare no hard and fast rules, but the following will gener-ally hold true:

• AHPs who are independent contractors are grant-ed clinical privileges

• AHPs who provide services, either as an employeeof a physician or the hospital, function accordingto a scope of practice or job description

There are exceptions to every rule, however. For ex-ample, a hospital may employ nurse midwives to pro-vide services in a prenatal clinic under the supervisionof a physician appointed to the medical staff, but itmay determine that the nature of the nurse midwives’practice requires a detailed delineation of clinical privi-leges. On the other hand, a hospital may determinethat a scope of practice is sufficient for physical thera-pists who provide services in the hospital as independ-ent contractors.

The important point is that the credentials committeeshould recommend the scope of practice or delineationof clinical privileges, whichever is the most appropriatefor a particular class of AHP. The board must thendecide whether to allow that particular class of non-physician practitioner to practice in the hospital or thehospital’s facilities.

Q: A privately owned ambulatory surgery centeropened in a small rural city. Appropriate specialtyprivileges and criteria were developed with theexception of oral surgery and podiatry.

Can the governing body of the surgery centermake the decision not to grant privileges to podia-trists and oral surgeons—or other surgical special-ties as a group—without creating an antitrust risk?If so, on what criteria can such a decision bebased?

A: In general, institutions are free to continued on p. 18


determine those services they will or will not provide.If a surgicenter decides it is not going to offer podiatricservices, then that institution shouldn’t process applica-tions from podiatrists. There need be very few criteriaupon which such a decision is based. The position ofthe board of directors concerning the scope of servicesprovided at the surgicenter should dictate the types ofpractitioners eligible for such clinical privileges.

It seems, however, that this surgicenter allows orthope-dic surgeons and other physicians to perform certainprocedures on the foot or ankle. If so, it is probablyunwise for the board to determine that the surgicenterdoes not provide podiatric services, since it certainlydoes. It would be better for the board to determinethose types of practitioners it will or will not permit toprovide services within the surgicenter itself. In theabsence of a nondiscrimination statute within the state,it is likely that the board of a surgicenter would beable to determine, on its own, those types of servicesthat would be provided and the types of practitionerspermitted to do so.

Q: Is it necessary to query the NPDB for AHPs?

A: It is necessary to query the NPDB for any individualto whom you will be granting clinical privileges.Therefore, if you grant clinical privileges to an AHP, itis necessary that you query the NPDB.

This is one of the reasons we recommend not grantingclinical privileges to most AHPs but allowing them topractice according to a scope of service or other writtenagreement. Remember that most AHPs are not licensedindependent practitioners (LIPs) practicing without su-pervision. It is only those individuals who must haveclinical privileges.

Medical staff office v. human resources

Q: How are the issues of competence being ad-dressed for AHPs? The medical staff office (MSO)has a much more thorough credentialing processthan that of the human resources office. Somehospitals are transferring the AHP credentialing tothe HR office as the JCAHO is saying that theprocess for all AHPs must be the same whether

the AHP is an employee of the hospital or not.

A: In this question, the word “credentialing” is usedinappropriately. Specifically, the medical staff office hasa much more thorough verification process than that ofthe human resource office. It is important to recognizethat the term credentialing means nothing unless other-wise defined within an individual organization. Forpurposes of this question, we will break the term cre-dentialing down into its three fundamental phases:

Phase one: information gathering, verification, storage, disseminationPhase two: Review and evaluation of collected informationPhase three: Decision-making

In light of these three phases, the medical staff officedoes not credential AHPs. The medical staff office orthe human resource department simply conductsphase one activities. Phases two and three must beconducted according to institutional policy. Such poli-cy could, as indicated above, involve medical staffcommittees, medical staff officials, or representatives ofmanagement.

Phase one activity must be done well, regardless ofwhich office does it. There should not be a circum-stance under which one office does it better than theother. It is certainly possible for a human resourceoffice to engage in phase-one verification activity. It isalso likely that a medical staff office could conduct thisactivity appropriately.

The second part of this question relates to the JCAHO.Apparently, the questioner believes that the JCAHOrequires that the credentialing process for all AHPsmust be the same, whether the AHP is an employee ofthe hospital or not. This is not true; there is no suchJCAHO standard. The JCAHO does require that all indi-viduals providing care within the hospital must be con-sidered competent through a defined process. Anemployee could be considered competent through aprocess involving the human resource department. Inan equally efficient manner, a nonemployee, in thesame discipline, could be found competent through aprocess involving the medical staff office and/or repre-

Allied health continued from p. 17


sentatives of the medical staff. The outcome must bethe same, not the process.

Q: A JCAHO surveyor suggested that we move ourAHPs from the medical staff to the humanresources department. Her reasoning was that ourbylaws include no provision for a fair-hearingprocess for AHPs. Should we have such a provi-sion in our bylaws? If not, why should we moveour AHPs under human resources?

A: The JCAHO requires that individuals with clinicalprivileges, whether medical staff members or not, begranted some form of hearing if the hospital takes cor-rective or disciplinary actions that affect those privi-leges. The JCAHO makes it clear that the “fair hearing”mechanism given to nonmedical staff members neednot be as extensive as the mechanism granted to physi-cians. If your medical staff bylaws or associated docu-ments do not contain a provision for giving an AHPsome type of a fair hearing, you should amend them toinclude such a provision.

The above applies only if the institution actually grantsclinical privileges to the individual AHP. If the hospitalpermits the individual to provide clinical services undersupervision, according to a job description or somescope of practice, there would be no JCAHO require-ment to provide him or her with a hearing if their per-mission to practice were revoked.

If a JCAHO surveyor suggested that you move yourallied health staff to human resources from the medicalstaff, he or she was simply providing you with a con-sultative recommendation and not referencing a specif-ic JCAHO standard.

Individuals working under defined supervision shouldnot be granted clinical privileges unless they are tobecome members of the medical staff.

Provide them with an agreement, scope of practice, orother document authorizing their work within the facil-ity. The rationale for this recommendation is as follows:

• You might easily avoid the necessity of providingthese individuals with a full-blown fair hearing.

• You will eliminate any confusion over whether ornot these individuals are part of the medical staff.

• The grant of authority to these individuals to pro-vide patient services need not require medicalexecutive committee or board review.

• Authorizing such individuals to practice underdefined supervision is usually much simpler thangoing the “privileging route.”

• Most providers in the AHP category do not main-tain an independent license, and nearly all prac-tice under defined supervision. (Under currentJCAHO standards, there is no compelling reasonto require these individuals to be granted clinicalprivileges.)

And obviously, it is very important for the institution toconduct a thorough evaluation of each practitioner’sability to provide clinical services, regardless ofwhether he or she requires supervision. Patient careand safety must always come first.

Q: You have recommended that the humanresources department credential LIPs practicingwith defined supervision. Can you please definewhat type of practitioners you are referring to?

A: I recommend that the human resources departmentprocess anyone who is employed by the organization.If the institution is employing someone who will alsobe a member of the medical staff, the individual mustacquire clinical privileges through the mechanismdefined within the medical staff bylaws.

LIPs practicing with defined supervision are just that—individuals licensed by the state to practice independ-ently according to a job description, policy, protocol,scope of practice, or other document defining therequired supervision. If the MEC determines that thetype of supervision is sufficient, that individual mayreceive permission to provide services within theorganization through a route that does not necessarilyinclude the MEC.

The human resources department must have someinvolvement in the processing of AHP applications.These individuals must, in fact, fill out employmentapplications; be subject to annual performance evalua-tion; and work with the human resources departmentto fulfill their orientation, continuing education andinservice requirements, health requirements, etc.Whether your institution chooses to continued on p. 20


Allied health continued from p. 19

have these individuals’ qualifications reviewed by offi-cials of the medical staff, including the executive com-mittee, is your own decision. You have a lot of flexibilitywhen it comes to defining the processing route for indi-viduals who will not be appointed to the medical staff.

Q: Two years ago, we changed our AHP credential-ing process from one facilitated entirely by themedical staff office to an interdepartmentalprocess including human resources, nursing, andthe hospital education departments. We designedthis process to try to treat our AHPs in a similarmanner as their hospital counterparts.

The departments other than the medical staffoffice want us to enforce a mandatory yearly safe-ty education update and age-specific competencyassessments. My opinion is that this is overkill.How far how should the hospital go in trying totreat AHPs the same as employees?

A: I congratulate you for moving the credentialingprocess for AHPs to a more interdepartmental processincluding human resources, etc., as it is a more effec-tive way to permit AHPs to provide services within anacute care hospital.

I also agree with you that it is not necessary for these“nonemployees” to participate in an annual safety edu-cation update and age-specific competency assess-ments. I do, however, believe that all individuals whowork within the hospital, whether employed or not,should have material concerning safety, infection con-trol, sexual harassment, etc. You are correct: Youredesigned your process in an attempt to make life eas-ier for the employees of physicians, and since all ofthese individuals are being supervised directly by theirphysician employer, it isn’t necessary that they partici-pate in age-specific competency assessments.

You should, however, require that the physicianemployer complete an evaluation to include in theAHP’s file on an annual or biannual basis. This neednot be complex, but it should indicate that the physi-cian continues to believe that

• his or her employee has good skills

• his or her employee good judgment • his or her employee has an adequate overall pro-

fessional performance Further, the physician must understand that the AHP isworking under his or her direct supervision; that his orher insurance policy provides coverage for the acts ofthis individual; and that the physician retains the over-all responsibility for all actions of his or her employee.

AHP supervision

Q: Who should supervise AHPs?

A: If the hospital grants AHPs permission to practicewithin its facility, it has a duty to supervise their work.Such supervision can be performed through the rele-vant department chief, supervising/sponsoring physi-cian, or other appropriate hospital supervisor. Hospitalpolicies on AHPs should specifically indicate who willsupervise each class of AHP allowed to practice in thehospital and how that supervision will be done.

The same supervision policies that apply to hospitalemployees should cover all AHPs (and physicians).The medical staff quality improvement system (andspecifically, department chiefs) handles supervision ofphysicians appointed to the medical staff. The relevantmanager and the department of human resourcessupervise employees. The hospital must superviseAHPs (meaning nonemployees, nonmedical staff mem-bers) in a similar manner.

Legally, all members of the medical staff could berequired to participate in supervision. All agree, as acondition of medical staff appointment, to accept rea-sonable assignments. However, that does not alwayswork. A new practitioner, such as a nurse-midwife orcertified registered nurse anesthetist, may receive per-mission to practice subject to his or her obtaining thewritten agreement of an individual appropriately quali-fied to supervise.

Q: We are a behavioral health facility. Is there sucha thing as privileging without supervision andprivileging with supervision, and would the RNsand LPNs come under the “with supervision”heading? Do the RNs have to be privileged for


everything they do in their job description?

A: Employed LPNs and RNs do not need to be privi-leged at all. They are generally permitted to practiceby a job description and are under the constantsupervision of nursing directors or other nursing man-agers. If a particular individual possesses a needed

skill that is not possessed by other RNs or LPNs, theinstitution can permit this individual to perform thisskill as long as it is within the scope of his or herlicense. No privileging is necessary at all. I generallyrecommend that clinical privileging be reserved forindividuals who will be practicing independently with-out supervision.

Appointment and reappointment

Process and paperwork

Q: Is it correct that the credentials file shouldgo to the department chief for review after allprimary-source verification is completed? Afterthat, should it then go to the MEC for review,and to the board of trustees for recommenda-tion? Could temporary privileges then be grant-ed while waiting for board approval?

A: The medical staff appointment process should pro-ceed as follows:

1. Primary source information is collected and verified.2. The department chair reviews and recommends the

application to the credentials committee.3. The credentials committee reviews and recom-

mends the application to the MEC.4. The MEC forwards the application to the governing

board for final approval.

In cases where an application presents no problems orred flags, a designated subcommittee of the board (ide-ally composed of the hospital’s CEO, chief of staff, andcredentials committee chair) can review and grant finalapproval. Such a subcommittee would report its actionsregularly to the entire board.

JCAHO standards give the nod only to a board sub-committee—nothing is stated with regard to the cre-dentials committee or the MEC.

Hospitals must write the use of a board subcommitteeinto its medical staff bylaws, as well as into its creden-tialing policies and procedures manual.

As for temporary privileges, in March 2002, the JCAHOreleased a clarification that makes it clear that organiza-tions can only use them when it involves an urgentpatient-care need or when an initial applicant with acomplete, clean application is awaiting approval of theMEC and governing body. Organizations cannot granttemporary privileges to combat administrative delays. Ifan effective expedited credentialing system is in place(as outlined in the two preceding paragraphs), it shouldeliminate the pressure for temporary privileges in thefirst place.

Q: During the approval process for appointmentand reappointment, is it necessary to obtain thesignatures of the president of the medical staffand the chair of the board?

A: No, it is not necessary to obtain signatures on appli-cations or reapplications forms reflecting the approvalof the medical staff president and/or the chair of theboard. The minutes of appropriately organized commit-tees reflect the approval of the MEC and the board.

An MSSP or other designated individual may stamp theapplication and reapplication in the appropriate spot toindicate that approval is documented in the minutes ofthe (specified) committee on such-and-such a date. Thesecretary to the board may always sign appropriatedocuments for the board chair reflecting board actions(provided such actions are documented within theminutes).

Q: Is there a standard regarding the use of elec-tronic signatures on credentialing forms?

A: I am not entirely sure why one continued on p. 22


would use an electronic signature on a credentialingform. However, if your institution permits physicians toauthenticate patient records via electronic signature, apolicy could be established permitting physicians toauthenticate medical staff applications the same way.Perhaps your organization uses an “electronic” appli-cation that a physician can complete and submit viahis or her computer. It is, however, my recommenda-tion that, in the absence of an electronic application,applicants and reapplicants must be required to attestto the accuracy and completeness of their credential-ing forms via standard, handwritten signatures.

Q: When a physician applies for reappointmentto our medical staff, we ask him or her to pro-vide information regarding professional liabilityclaims, either pending or settled, over the pasttwo years. We also write directly to the insurancecompany to verify coverage and to obtain claimshistory information. Do we really need to takethis step? I have talked to several hospitals thattake the word of the physician and do not verifythe information. Is that appropriate?

A: Your hospital is correct in verifying insurance cov-erage and claims history. Simply taking the physician’sword for it is no longer sufficient. It is absolutely nec-essary that hospitals verify all information collectedduring the application and reapplication processes.

Q: I oversee the credentialing process at a long-term care (LTC) facility. Our parent organizationowns two LTC facilities on one campus, eachwith its own LTC license and administrative staff.The department of health surveys each individu-ally. Could we use one set of credentialingrecords (applications and verifications) for bothLTC facilities, or must each facility receive a sepa-rate application/questionnaire/release and verifi-cations records from the physician? Again, both facilities are owned by the same organization andshare the same list of attending physicians.

A: You may absolutely use one set of records, appli-cations, and verifications for both facilities. The onlyexception to this rule is the NPDB report. If yourfacilities maintain separate access numbers for the

NPDB, you must acquire a NPDB report for each facili-ty. If each of your LTC facilities is considered a singleprovider by the NPDB, you may then access the NPDBreport once and use it within both of your fully ownedfacilities.

I recommend that your applications and reapplicationsindicate that they apply to both facilities specifically.Because your institutions are separately licensed, it isnecessary for the organization’s board to appoint andreappoint physicians to both facilities (i.e., “We theboard appoint Dr. William Smith to facility A and tofacility B.”).

Q: At our facility, if the credentials committee hasconcerns about an applicant’s appointment orreappointment, they inform the MEC for furtherinput. The MEC then follows the issue for a monthor more and then makes a final recommendation.Under these circumstances, does the applicantneed to be re-reviewed through the credentialscommittee, or is it okay to simply forward a rec-ommendation to the governing board?

A: Yes, it is okay. The MEC need not refer the issueback to the credentials committee, but should make itsrecommendation to the governing board for a finaldetermination.

Q: I recently heard that the JCAHO requires thesignature of only the department chair/divisionchief on a reappointment application, and thatminutes of the credentials committee, MEC, andboard of trustees need to reflect only action takenon the reappointment application. Is this informa-tion accurate?

A: Actually, the JCAHO does not require a “signature”on any specific document. It does require that the de-partment chair conduct an evaluation and make a rec-ommendation concerning any individual applying forclinical privileges within the department. The depart-ment chairperson could document his or her evaluationand recommendation in a number of ways. The mostcommon way is by completing a carefully designedform in which the department chair indicates his or herassessment of the applicant’s education, training, expe-

Appointment and reappointment continued from p. 21


rience, current competence, ability to relate to others,adherence to bylaws, and other indicators of continu-ing qualification. Certainly the department chairpersonis not “required” to sign the application or the reappli-cation.

If the application and reapplication contain a signatureblock for the department chair, he or she certainly shoulduse it to document his or her assessment and evaluation.

The same general logic is true for the credentials com-mittee, MEC, and board. The Joint Commission doesnot require the signature of a credentials chair, chief ofstaff, or board member on the application itself. Itrequires the MEC to formulate a recommendation forconsideration by the board, and requires the board tomake a decision to appoint and/or grant clinical privi-leges. Such a decision could be memorialized in theboard minutes, a separate board report, a specific formdesigned just for that purpose, or by a board member’ssignature on the application itself.

In responding to this question, it must be stressed thatthe JCAHO expects a fairly comprehensive evaluation ofan individual physician’s qualification for appointmentand/or clinical privileges. A signature on a form atteststo nothing unless it is preceded by documentation of acareful and methodical evaluation of clinical judgment,technical skill, and overall professional performance.

Policies and forms

Q: Our credentials committee is conducting anannual review of the form letters we send duringthe initial medical staff appointment process. Onecommittee member suggested adding the follow-ing questions to the training form, the peer refer-ence form, and the hospital affiliation form. Theyare as follows:

1. Would you be pleased to have this doctor stayand practice in your community?

2. Would you have this doctor join your group? 3. Would you take your family members to this

doctor?

Are these questions appropriate?

A: Question #1 is excellent. You might reword question

#2 as follows: “If your specialty group were searchingfor a new physician, would he or she be a viablecandidate for employment or recruitment?” Question#3 is probably not appropriate because physiciansgenerally base their “family physician” choices on awide variety of factors, many of which are independ-ent of competence issues.

A better question might be, “Would you be comfort-able having a neighbor or friend treated by thisphysician?” You certainly could add these questionsto your forms, and you will probably receive relative-ly straightforward information as a result. Most appli-cants have no problems in their practice backgroundsand enjoy the confidence of their colleagues.

Q: Do you have samples of questions to ask dur-ing the clinical interview that focus on patientcare issues?

A: You should base questions for the clinical inter-view (if held) on the applicant’s specialty and back-ground. I recommend that you break them downinto three components:

1. Questions needed to “flesh out” the applicationitself. Such questions seek further informationabout omissions in the application, obviouserrors, potential falsifications, etc.

2. Questions concerning the applicant’s intendedpractice plan for the institution. Such questionswould range from, “How do you anticipate help-ing the institution and medical staff with its mis-sion?” to “Do you agree to provide emergencybackup when requested by the emergencydepartment ED physicians?”

3. Clinical questions designed to “test” the appli-cant’s current knowledge, judgment, and skill.Such questions would obviously vary by special-ty. You could quite easily phrase them as follows:“Please describe a recent interesting or complexcase in which you were the primary physician.Describe your workup, diagnosis, use of consult-ants, etc.”

Use an interview form to capture the continued on p. 24

general nature of the questions and the responses. It isnot necessary to keep a detailed account of all questionsand answers.

Q: What is the best type of form to use when aphysician comes back to work from an injury orillness?

A: Unfortunately, the answer to this question is farmore complicated than the use of a form. It dependson a number of things:

1. Was this a formal leave of absence? If so, thebylaws or a policy should indicate what shouldhappen to reinstate the physician after a leave ofabsence.

2. What was the term of leave? Thirty days? One year?

Consider where the physician was in the reappoint-ment cycle. Generally speaking, leaves of absence canbe granted for up to two years, depending on the situa-tion. If the leave is for one year or more, many hospitalsrequire a new reinstatement application. If the reappoint-ment expires during the leave, the hospital should re-quire the physician to complete the full reappointmentapplication as part of reinstatement.

Q: We are a semi-urban hospital of approximately200 beds and 500 physicians on staff. Most of thephysicians routinely complete their patient rec-ords within an appropriate time period, but threeconsistently do not. Our MEC is reaching thebreaking point on this issue. The three physicianshave been brought before the MEC six times overthe past two years. In each of these sessions, theMEC seems quite purposeful in suggesting thatthey mend their delinquent ways and completetheir records, but invariably, the three physiciansrelapse and delinquent records continue to mount.

What might our MEC contemplate?

A: The MEC has many options at this point. Based uponour research with the institution that asked this question,it is clear that this executive committee has the couragenecessary to tackle this issue. They have, in fact, dealtwith more difficult issues in the past. I suggest the fol-lowing recommendations for consideration by this MEC.

The MEC might consider passing a self-enforcing policyregarding medical records completion. Its current poli-cy indicates that a physician who does not completehis or her records within a defined period will be sus-pended. While on suspension, the physician’s clinicalprivileges to admit or schedule surgery are also sus-pended. The MEC might consider adding to this policya provision that says a physician whose name appearson the suspension list six times in a 12-month timeperiod will automatically lose medical staff membershipand all clinical privileges. Such physicians will beallowed to apply to rejoin the medical staff, but firstwill be required to interview with the credentials com-mittee and the board of directors to explain how theyplan to complete their records in a timelier manner.Such automatic termination of appointment and privi-leges (which will take place after the discharge of thephysician’s current patients) will not be subject to a fairhearing and appeal process.

The MEC might consider passing a policy indicatingthat physicians who have been on the suspension listmore than three times in any calendar year will befined $10 per delinquent chart per day, in addition toautomatic suspension for failure to complete records. Thephysician should also be informed that he or she wouldbe ineligible for reappointment unless all fines are paid.The chief of staff could appoint these physicians as thepermanent members of the medical records committeewith a requirement that the committee meet weekly untilthe problem of incomplete records has been solved.

Appointment and reappointment continued from p. 23

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02/03 SR603

hugh greeley responds - hcpro · hugh greeley responds: ... dea verification is also included in...

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