Download Hugh Greeley Responds

Hugh Greeley
Responds
Volume 1:
Credentialing Concerns
Hugh Greeley answers readers’ most pressing
credentialing and privileging questions
A supplement to HCPro, Inc. publications
Dear BOC subscriber,
I hope that you find this compilation of Hugh Greeley’s answers to common credentialing questions helpful 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, my
editorial 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 of
BOC’s sister publication, Medical Staff Briefing. To order a copy of this special report, Hugh Greeley
Responds: 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 Hugh
Greeley Answers Common Credentialing Questions). Visit www.hcmarketplace.com/Prod.cfm?id=663 for
more 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. Cutchin
Senior Managing Editor
HCPro, Inc.
[email protected]
Table of contents
Credentialing basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Privileging basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Managed care credentialing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
Allied health professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
Appointment and reappointment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
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.
2
Hugh Greeley Responds: Volume I—Credentialing Concerns
Credentialing basics
Primary-source verification
Q: Is verification of liability insurance and Drug
Enforcement Agency (DEA) certificates mandatory? If it is mandatory, what are the guidelines? Is
written verification required, or can it be via telephone or fax? If it is done by phone, how can I
verify that I actually did the verification?
A: Verifying a physician’s DEA number is indeed
required by the JCAHO. However, since the DEA
won’t release this information, the applicant must
supply the hospital with proof of his or her DEA
number(s) and a copy of his or her DEA certificate.
The JCAHO, the American Accreditation Health Care
Commission (formerly URAC), and the National Committee for Quality Assurance (NCQA) consider this
as acceptable primary-source verification.
DEA verification is also included in the American
Medical Association (AMA) Physician Masterfile and
in National Practitioner Data Bank (NPDB) reports,
but unfortunately, the JCAHO does not accept either
of these databases as primary sources for DEA verification. As of July 1, 2001, NCQA accepts the AMA
Physician Masterfile as a primary source for DEA status, but not the NPDB. Some hospitals opt to use the
National Technical Information Service (NTIS), which
can be costly (for more information on NTIS, go to
www.ntis.gov/product/dea-csa.htm).
As for primary-source verification of malpractice insurance, it is not specifically required by the JCAHO,
but it can be used as evidence of an applicant’s ability to perform the privileges he or she requests.
Q: Could you please tell me your interpretation of
a “verified” DEA certification?
A: Verifying a physician’s DEA status was, up until
now, extremely difficult. A physician completing an
application or a reapplication would indicate his DEA
number. Most agencies, whether state or federal, would
routinely refuse to verify whether a physician maintained a valid DEA number. Today, however, the NTIS
will provide hospitals with mechanisms to verify DEA
status. Such mechanisms are, however, fairly costly and
must be routinely updated. Certain CVOs routinely
sweep available federal data to verify a physician’s
DEA status.
In the real world, however, most institutions do not
verify a physician’s DEA status. They may make an attempt to verify this information by sending a letter to
an organization that could verify it.
Q: What would be considered acceptable verification of malpractice history? Should we be checking with the current carrier for any pending or
dropped claims? If so, how far back is reasonable
to check whether there is more than one carrier?
A: The JCAHO requires hospitals to verify all medical
staff applicants’ evidence of current clinical competence. This evidence should include “involvement in a
professional liability action under circumstances specified in the medical staff bylaws, rules and regulations,
and policies (MS.5.5.3).”
However, it is entirely up to the individual hospital to
decide exactly what criteria it will require to demonstrate a physician’s ability to perform his or her privileges. Whatever they are, they must be written into
the medical staff bylaws.
I recommend that health care organizations check with
a physician’s current malpractice insurance carrier(s) for
any pending or dropped claims, as well as any suits and
settlements. I also recommend checking as far back as
10 years. Please note that the 10-year suggestion is not
mandated by the JCAHO or any other accrediting body
or government agency. It is recommended for thorough, high-quality credentialing.
Many insurance companies charge a fee for a verification letter. But despite these costs, many health
care consultants recommend that hospitals verify insurance coverage. It’s an excellent risk management
measure. But again, it’s not specifically required.
In addition to checking with the insurance carrier(s),
organizations should also query the NPDB. Some
states, such as Florida, also make available full details
of malpractice claims through a state database. If the
cases aren’t egregious and the
continued on p. 4
Hugh Greeley Responds: Volume I—Credentialing Concerns
3
Credentialing basics
continued from p. 3
information provided by the applicant is consistent
with that of the insurance company, the NPDB, and
the state material, no further investigation is necessary.
Q: We are having difficulty obtaining written verification from our state medical board for licensure
on our physicians. The board does have a Web site
and wants us to use it. However, we also want
written verification as well as telephone verification, but the board feels that isn’t necessary. Will
we be in the JCAHO compliance if we use the Web
site, a secure copy of licensure (which we do), and
receive e-mail and telephone verification?
A. Yes, in general you will be in compliance with the
JCAHO if you use a secure Web site organized by the
state licensure department. You do not need a copy of
the physician’s license because obtaining a copy does
not in any way ensure that it is, in fact, the physician’s
true and accurate license. The e-mail verification you
received is excellent. You do not need to obtain telephone verification.
Remember, the ultimate objective is to assure yourself
that the physician does maintain a current license
authorizing him or her to practice medicine or osteopathy. A Web site is an excellent mechanism to use for
verifying current licensure. You are not obligated to
establish multiple redundant systems in this area.
Q: In reviewing applications of physicians who have
practiced in their specialty for more than 20 years,
how much effort should go into verifying their medical school, internship, and residency, especially in
cases where previous practice sites have closed or
references have died? Is there a cutoff?
A: The hospital should employ standard procedures
concerning medical school, internship, and residency
verification. Hospitals should use the AMA Physician
Masterfile to verify basic education and training for
physicians who have been out of medical school and
residency for a substantial period of time. It is more
important for the institution to verify past practice
sites and to obtain references from health care professionals who can attest to the applicant’s current clinical competence.
4
Sometimes, it is nearly impossible to obtain information
from the “primary source” concerning medical education and certain residency programs. Additionally, military service is occasionally difficult to verify due to destruction of military files during fires, etc. In such cases,
a hospital should use standard channels to verify
medical education, training, and internship. When
these fail, reliance on the AMA Masterfile is perfectly
appropriate.
Q: It has always been my understanding that a
hospital is not in compliance with the JCAHO if it
sends a request for a reference letter without providing a copy of the physician applicant’s requested 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 a
copy of an applicant’s requested privileges when
requesting a reference letter. It is, however, an excellent idea. There is really no way an individual can
attest to a physician’s specific qualifications if that individual does not know which clinical activities the
physician will carry out.
It’s not a difficult or time-consuming step. Simply photocopy the requested privileges, slip them into the envelope
with the reference request, and forward it to the appropriate individual. Most people will take a moment to scan
the privileges in order to provide a focused reference.
Q: On new applications, how far back am I required to check on a physician who states he had
an alcohol problem in 1983? I’m being questioned
as to why I need to know about events that happened so long ago.
A: Actually, the answer to this question should be in your
policy. In the absence of a policy, it should be your policy to develop a policy. Many medical staffs now identify
the time periods necessary for verification. Verifying malpractice suits as far back as 1983 is probably not relevant
for most physicians. Verifying health status that far back
may also be irrelevant, particularly if the physician has
had an event-free practice pattern since then.
If a physician discloses that he or she had a problem
Hugh Greeley Responds: Volume I—Credentialing Concerns
with alcohol or substance abuse in 1983, the hospital
must verify that there had been no relapses for this
physician in the recent past. There is very little reason
to obtain further information concerning the treatment
for the alcoholism problem as far back as 1983. It is
far more important to make sure that the physician
is currently not an active alcoholic or substance
abuser.
Q: What is your take on using Web sites for primary-source verification? Our JCAHO mock surveyor stated that it is acceptable, as long as the
site is firewall-protected and is maintained by
that state’s medical board or licensing agency.
A: Yes, it is perfectly appropriate for institutions to
use Web sites for primary-source verification of information on a medical staff application. The position
espoused in your question is an accurate reflection of
the JCAHO’s current policy.
Institutions should, however, recognize that many of
the questions and requests on applications are present
because the institution itself wants the information, not
because the JCAHO requires it. Information required
by the institution itself can be verified via any source
deemed acceptable to the institution. Information specifically required by the JCAHO (i.e., license, education, training, and current clinical competence) must be
verified via a primary or acceptable secondary source,
such as the AMA Physician Masterfile.
Q: I whole-heartedly support the “new credentialing standard.” However, our corporate compliance officer is insisting that we also perform
credit checks on all physicians. I feel like this is
going too far and crossing way over the line. Is
this a common practice?
A: No, a credit check should not be part of a routine
credentialing background check. Reserve it for highrisk employed physicians.
Q: If a hospital participates in the credentialing
process, how can it obtain information on the
“private out-of-hospital” practice of a physician?
Such information may adversely affect the physician’s actual qualifications and the original credentialing approval.
Hugh Greeley Responds: Volume I—Credentialing Concerns
A: The hospital should simply request this information. 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, the
hospital can simply require that the physician furnish
the information. Failure to do so within a timely manner could result in immediate summary suspension
from the staff, voluntary relinquishment of the physician’s privileges until the physician complies with the
request, or voluntary resignation from the staff according to the staff or hospital bylaws or policy.
Q: Which types of questions are considered to be
“out of bounds” when interviewing a medical staff
applicant?
A: Your credentials committee should not ask questions
relative to the applicant’s age, sex, national origin, sexual
orientation, religion, marriage status, or any other topic
that is entirely unrelated to professional competence,
professional performance, or ability to relate to others.
You might also review your medical staff bylaws, as
they must contain a provision concerning this issue. If
they do not, I recommend that your medical staff
bylaws state that neither membership nor clinical privileges will be based in any way upon the applicant’s
age, sex, national origin, or religion. These are generally referred to as nondiscrimination provisions.
Q: Can the medical staff office deny an application
without medical staff involvement based on malpractice history?
A: No, the medical staff office may not deny any application. The medical staff office may choose not to
process an application because of the presence or
absence of certain information. For example, a hospital
continued on p. 6
could refuse to process the
5
Credentialing basics
continued from p. 5
application of a physician who recently had a substantial number of malpractice cases. The presence or
absence of malpractice cases does not necessarily
have anything to do with the quality of an individual
physician’s practice.
However, a physician who has more malpractice
cases during the most recent past is obviously different from the norm. Place the burden on this applicant
to demonstrate that the malpractice actions were not
based on problems with patient care, patient relations, billing practice, etc. before the credentials committee considers the application.
Q: Our medical staff is considering requiring
board certification for medical staff membership
and privileges. Our legal counsel has stated that
the Medicare and Medicaid Conditions of Participation (COP) specify that “the governing
body must ensure that under no circumstances is
the accordance of staff membership or professional privileges in the hospital dependent solely
upon certification, fellowship, or membership in
a specialty body or society.” Legal counsel has
interpreted this to mean the COP would be violated if the absence of board certification were
the sole basis for denying medical staff membership and privileges.
A: Many hospitals nationwide require board certification/admissibility as a requirement of medical staff
membership. From your question, it seems that your
legal counsel is overly conservative. They are accurately quoting the Medicare COP, but they are inaccurately interpreting it.
Accordance of staff membership means that the governing board cannot place someone on staff simply
because he or she is certified. The COP are moot on
the issue of denial of medical staff appointment due
solely to the fact that someone is not certified.
There are apparently a number of states in which the
state’s attorney general or the licensure statute is more
specific on this issue than in other states.
Unfortunately, your institution should seek the advice
of another health care attorney to resolve this issue.
6
Q: Is there an accepted average industry cost to
credential a physician? Also, are there any breakdowns on initial v, ongoing costs?
A: Yes, estimates in surveys show that the cost of
processing an initial application from a new physician
ranges anywhere from $480 to more than $1,000. The
range of estimates in surveys depends upon the number of physicians credentialed and the extent of the
credentialing activity.
It’s easy to determine the overall cost of a credentialing
program within an institution. The director of finance
could give a dollar value to the administrative services
necessary to support this activity—including rent, utilities, equipment, salaries, and benefits—with each of
these apportioned for all those individuals who participate in some manner in the credentialing process.
These individuals would include the MSSP, chief executive officer, vice president of medical affairs, and any
others in some way involved with the credentialing
process.
Factor in additional costs in the form of opportunity
costs. These would include the time spent by department chairs, credentials committee members,
executive committee members, and board members
on credentialing activities.
Other costs associated with credentialing include
printing, postage, FedEx, telephone, fees necessary
to obtain relevant information concerning credentialing, as well as the cost of any CVO.
Once you determine the overall cost of the credentialing program, divide that cost by the approximate
number of credentialing transactions, appointments,
or reappointments made during a single year. The
resulting number would be the approximate cost of
credentialing within your organization.
Applying physicians could pay a fee that covers the
cost of processing the application. The reapplication
costs for physicians are somewhat less than those for
initial application because the institution already possesses considerable information concerning the reapplying physician.
Hugh Greeley Responds: Volume I—Credentialing Concerns
NPDB/AMA Physician Masterfile
Q: Does the NPDB include a thorough search of
the Office of Inspector General’s (OIG) sanction
list to detect providers excluded/sanctioned by
Centers of Medicare & Medicaid Services (CMS)? If
so, can we rely on the NPDB results?
A: The NPDB has included information from the OIG’s
List of Excluded Individuals/Entities since April 1997,
when Medicaid/Medicare Exclusion Reports (MMERs)
against licensed health care practitioners were added
through a collective effort of the Health Resources and
Services Administration, the OIG, and CMS. The NPDB
contains MMERs from February 4, 1981, to the present.
To access the sanctions list directly, go to the OIG’s Web
site, www.dhhs.gov/oig/cums an/index.htm.
Q: When you query the NPDB, you can get a report
of sanctions and restrictions. Does it also include
debarment report information?
A: For information concerning the contents of the NPDB,
contact the databank. The databank has information concerning settlements paid on behalf of a practitioner in a
malpractice case, disciplinary actions taken by legitimate
peer review organizations, licensure actions taken by various states or other governmental units, as well as certain
other actions taken by the federal government.
The JCAHO does not specify how much weight should
be given to NPDB reports. The database was not created
to replace traditional means of credentialing but to supplement them. It should serve as another resource that
hospitals, state-licensing boards, and other health care
entities can use to conduct a thorough check on practitioner qualifications. Reports should be evaluated rather
than taken at face value, and you should provide practitioners with the opportunity to furnish explanations.
called URAC), also considers the AMA Physician
Masterfile a primary source of information for verifying
licensure, medical education, residency training, board
certification, DEA registration status, and state and federal disciplinary sanctions.
In the fall of 1995, the AMA established to the JCAHO’s
satisfaction that it was prepared to meet all the JCAHO
requirements for CVOs. As a result, the JCAHO officially recognized the AMA Physician Masterfile as a “designated equivalent source . . . [of] specific items . . .
identical to the information at the primary source.”
The significance of this designation is that organizations
can regard information from the AMA Physician
Masterfile as just as authoritative as information
obtained directly from primary sources. Please note,
however, that the JCAHO currently regards the
Masterfile as an equivalent source only for two specific
items: medical school graduation and completion of
residency. Although the Masterfile contains far more
information about each physician than the items listed,
the JCAHO does not permit use of that information for
primary-source verification.
Q: I recently heard that the JCAHO is not accepting the AMA Physician Masterfile as primarysource verification of medical school completion
if it is a foreign medical school. Do you know
whether this is correct?
Q: Is the AMA Physician Masterfile considered a
primary source?
A: Ideally, hospitals should verify the credentials of foreign medical graduates (now often called international
medical graduates) in exactly the same way as they
verify the credentials of graduates of U.S. medical
schools. In the past, some overseas sources were not
as responsive to verification requests. Therefore, in the
past, the JCAHO allowed hospitals to contact reliable
secondary sources—agencies that collect information
from primary sources—when the hospitals could
demonstrate significant but unsuccessful attempts to
obtain primary-source verification.
A: The NCQA recognizes the AMA Physician Masterfile
(now called the AMA Physician Profiles) as a primary
source to verify medical education, residency training,
specialty board certification, DEA registration status,
and Medicare/Medicaid sanctions. The American
Accreditation Health Care Commission, Inc. (formerly
For example, a hospital had to be able to present a
copy of an unanswered letter to a foreign residency
program as documentation that it tried to obtain primary-source verification. Then the hospital could
obtain verification from the AMA Physician Masterfile
continued on p. 8
or the Educational Commission for
Hugh Greeley Responds: Volume I—Credentialing Concerns
7
Credentialing basics
continued from p. 7
Foreign Medical Graduates (ECFMG).
However, the JCAHO’s position regarding the verification of overseas medical school graduation has
changed. The JCAHO now considers the possession
of an ECFMG certificate as primary-source evidence of
graduation from medical school (an applicant’s
ECFMG certificate must be verified with the ECFMG).
There is no change in regard to verification of overseas graduate training—residencies and fellowships—
because the ECFMG does not deal with this at all.
The AMA Physician Masterfile usually begins recording data on foreign medical graduates upon their
entrance into medical residency training programs
approved by the Accreditation Council for Graduate
Medical Education. It receives background information
on foreign medical graduates from the ECFMG and
also receives information from other organizations as
the training and careers of these graduates develop.
I have not heard of any instances in which a JCAHO
surveyor has not accepted the AMA Masterfile profile
as an appropriate means for verifying a practitioner’s
completion of a foreign medical school. The AMA
relies on ECFMG information for verification of foreign medical school graduation, and its literature indicates that this information may be relied upon as primary-source information.
Q: Does the JCAHO recognize the American
Board of Medical Specialties (ABMS) as primarysource verification for medical school or graduate medical training, or is the AMA Physician
Masterfile the only other alternative primary
source other than the schools?
A: Currently, the JCAHO does not recognize certification through the ABMS as primary-source verification
for medical school or postgraduate education and
training. The NCQA will recognize board certification
as evidence that a physician has completed medical
school and appropriate residency training.
It must be pointed out that certification by the ABMS
does not, in and of itself, guarantee that a physician
completed an approved residency program. There are
8
many physicians certified in the United States who
were certified through a “grandfathering” clause that
did not require completion of an approved residency.
It is highly unlikely, however, that a physician certified
by the ABMS would not have completed medical
school. Therefore, it seems reasonable that the JCAHO
should use board certification as evidence of completion of medical school.
There are, of course, legitimate reasons why the
JCAHO requires independent verification of medical
school, residency training, and board status. These
three checkpoints in a physician’s practice career allow
organizations to determine whether they are dealing
with an “imposter” physician. Unfortunately, such individuals 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 there
any requirement to obtain physician profiles from
the AMA? If you do obtain a profile, do you still
need to send out letters to the medical school verifying that physician’s training?
A: Currently, there is no requirement to obtain the physician profiles from the AMA. I do, however, recommend
that all facilities consider making the AMA Physician
Masterfile a part of their routine credentialing activities.
This information can be extremely useful to credentials
committees as they process applications from physicians.
If an institution does receive the AMA Physician
Masterfile printout for an individual physician, it isn’t
necessary to reverify the physician’s completion of
medical school or the physician’s completion of an
approved residency-training program. The AMA information on these two issues is verified from the primary
source, and hospitals may rely upon it as though it is a
primary source. However, you still must obtain information concerning current clinical competence from a
residency director if the applicant recently graduated
from a residency program. If the applicant has been
out of a residency program for two or three years, the
residency director’s attestation of current clinical competence is not as useful as that of a physician in a
more recent practice site.
Hugh Greeley Responds: Volume I—Credentialing Concerns
Privileging basics
Specific privileging criteria
Q: I am trying to develop a policy on how to delineate privileges to practitioners who function in a
capacity for which there may be no applicable
specialty board. Specifically, is there a board for
pediatric developmental delay? If not, what sort of
education, training, etc. should a practitioner have
in order to hold privileges in this field?
A: No, there is no specialty board for pediatric developmental delay.
It is up to your credentials committee to carefully
define the criteria that practitioners must meet for
acquiring clinical privileges in pediatric developmental
delay. The criteria might, in this instance, look like the
following:
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
necessary for that entity to develop its own credentialing and privileging policies and procedures.
Q: How do you credential physicians whose primary specialty is research (PhD)? These physicians do not have licenses, DEA numbers, or malpractice insurance. They come to the facility and
research different cases and are considered consultants. Is it necessary to privilege them?
A: Because this type of physician will not engage in
clinical practice, it is not necessary to grant them clinical
privileges. If your institution includes these physicians as
members of its medical staff, you must recognize that
they may not, in many instances, meet your membership criteria. Very often, medical staff bylaws require
physicians to hold DEA certificates and malpractice
insurance policies to qualify for medical staff appointment. It is far more reasonable for your institution to
determine whether these individuals are, in fact, good
researchers. If they are, either hire them or appoint
them specifically to conduct research. Do not grant
them clinical privileges, as they will not engage directly
in clinical practice.
Q: Our small rural hospital plans to build and
open an ambulatory surgery center in the near
future. Does this mean we will need to develop
specific credentialing and privileging procedures
for the practitioners who will work in the center,
or should we use the same methods as we do at
our hospital?
Q: What documentation should we request from a
family practitioner who wants to perform emergency C-sections without obstetric surgical backup? The physician has submitted some documentation of his experience in this area, but how
much is enough? We’ve never processed this type
of request before.
A: If the ambulatory surgery center will operate as a
division of your hospital, it is not necessary for you to
develop further privileging procedures for practitioners
wishing to perform surgery there. You will, however,
have to make sure that your current privileging system
(which perhaps authorizes practitioners via a “privileging list”) accurately reflects the procedures and treatments your surgery center will offer. If not, it will
require some minor amending.
A: The best way to tackle a privileging issue for which
you have no policy is to develop a policy. The request
itself would be tabled while the credentials committee
and MEC review the issue of C-section privileges and
recommend an objective policy for consideration by
the board. Such a policy should include the minimum
education, training, and experience required by the
institution prior to granting C-section privileges to any
practitioner.
If, however, the ambulatory surgicenter will operate as
a separate legal entity (e.g., a joint venture), it will be
Q: Generally speaking, obstetricians (OBs) are privicontinued on p. 10
leged based on the procedures
Hugh Greeley Responds: Volume I—Credentialing Concerns
9
Privileging basics
continued from p. 9
they perform. Is there any guidance or precedence
for adding a statement to the privileges of OBs
regarding “caring for general medical problems
considered non-life-threatening with appropriate
consultation”? Or are the primary care skills they
acquire during residency training generic enough
that any licensed OB can do them without specifying them in a privileging document?
A: This question relates to the development of a core
set of privileges for individuals trained in obstetrics.
Traditionally, OBs have been granted clinical privileges
in two categories:
1. To admit, workup, diagnose, and manage patients presenting with illnesses or injuries of the
female 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 further
define the clinical privileges of OBs to provide general
medical care to women if it believed basic OB training
and experience encompassed this area.
The clinical privileges should be written to avoid any
confusion about what a practitioner may or may not
do. If an OB has privileges restricted to treating illnesses and injuries of the female reproductive system and
performing deliveries, etc., there would be confusion if
an OB attempted to provide definitive care to a female
patient with congestive heart failure. A “poor outcome”
in doing so might cause concerns about whether the
OB was practicing outside of his or her “scope” of
privileges.
Q: An urologist at our hospital has applied for
privileges in lithotripsy. Where would I find information to help me determine how many lithotripsy procedures he should have performed in the
past to demonstrate competence. I do send a copy
of his requested privileges to all current and former hospitals/Residency Directors. Is there a
guideline to how many procedures a physician
needs to have performed?
A: To determine appropriate qualification criteria for
10
requesting lithotripsy privileges, your institution should
review information provided by your existing urologists
about performing this particular procedure. It should
also collect any data available from third parties such
as medical/surgical specialty boards, colleges, and/or
academies.
Please note that absolutely no “magic” number of procedures exists for competence in the area of lithotripsy.
It is undoubtedly true that many urologists could
obtain competence in this procedure after performing
only a few of them. Other physicians may require
greater numbers in order to achieve competence. It is
critical to understand that a physician’s qualification for
clinical privileges doesn’t depend so much on numbers
of previous procedures performed but on whether his
or her experience was in the direct or indirect treatment of the illness necessitating lithotripsy, overall
experience in treating patients with urological conditions, completion of approved postgraduate training,
and successful completion of medical school.
A physician who has performed many procedures
without having undergone appropriate postgraduate
training would not, in most institutions, qualify for clinical privileges. Along the same lines, a physician who
has completed an approved postgraduate training program would not qualify to perform many procedures if
he or she had not performed them during the residency or within the previous two to three years. Competence
is a function of education, training, and successful
experience.
Q: Are facilities out of compliance with JCAHO
standards if they send out requests for letters of
recommendation without including a list of the
privileges sought by the applicant?
A: There is no requirement that a copy of the requested privileges must be sent out with requests for professional references. It is, however, an excellent idea.
There is really no way an individual can provide an
adequate reference about an applicant’s qualifications if
he or she does not know which clinical activities the
applicant will engage in.
Many individuals (credentialing consultants, surveyors,
Hugh Greeley Responds: Volume I—Credentialing Concerns
and even health care attorneys) recommend this practice. It is quite easy to photocopy the requested privileges, slip them into the envelope with the reference
request, and forward them to the appropriate professionals. Most will, in my experience, take a moment to
scan the privileges and provide an appropriate reference letter.
Q: If, within the department of medicine, the division of cardiology adopts and passes its own privileging criteria, must they pass through the credentials committee before the department chair can
use them? What would regulatory agencies say
about privileging criteria that’s used without the
credentials committee’s approval?
A: Make it clear to everyone in your organization that
individual departments or sections are not authorized
to create their own privileging criteria. They may participate in establishing criteria by submitting recommendations to the MEC for ultimate approval by the
governing board. If departments did create their own
criteria and used them to exclude other practitioners,
the antitrust implication could be considerable. Such an
act could, in fact, constitute a per se violation of the
Clayton and Sherman Antitrust Acts.
Privileging criteria should be drafted by relevant specialty groups, departments, or sections and submitted
to a committee authorized by the MEC to receive and
consider such criteria (e.g., the credentials committee).
The committee then should submit the criteria to the
MEC for its consideration. If the MEC finds no problem
or controversy with the criteria, it should forward its
recommendations to the board for final approval.
Pain management
Q: Are there any specific criteria for physicians
requesting privileges in pain management? Should
they submit documentation of any special training?
Should their credentialing process be any different
from any other members of the medical staff?
A: The credentialing process for a physician interested
in pain management privileges need not be any different from that of any other medical staff member. The
specific privileging criteria should be specific to the
pain management discipline, as opposed to bypass sur-
Hugh Greeley Responds: Volume I—Credentialing Concerns
gery, for example. Of course, physicians interested in
pain management privileges should be required to
demonstrate that they have training in pain management techniques.
Such training could have taken place in a formally
recognized residency or training program, or in postgraduate continuing medical education courses taught
under the auspices of a recognized university or training center.
Criteria for pain management privileges should always
include the minimum amount of education, training,
and relevant experience the applicant must possess.
You should also require peer references specific to
pain management.
Q: We have a physician practicing pain management. Questions have been asked about his skills
with cervical discograms, including two cases of
high spinals following these procedures. He is
required to have a proctor for his next six cases.
His proctor (the only one who will serve out of
the few available) refuses to proctor him on any
more cervical discograms. What can we do?
A: Under these circumstances, the MEC or officers of
the medical staff must consider the issue and determine
whether they believe it is safe for this individual to
continue to perform cervical discograms without concurrent monitoring. It appears that the hospital is
unable to provide an individual to review his work on
an ongoing basis.
The MEC/hospital has a number of perfectly legitimate
alternatives to choose from, including the following:
1. The institution could “command” that members of
its staff participate in proctoring as a responsibility
of medical staff appointment. I do not suggest that
the institution select this option, as it will undoubtedly prove unpopular and ineffective. Nor do I recommend that physicians be obligated to “proctor”
an individual if they have determined, for reasons
known to them, that they’re unable to do so.
2. The institution could hire an individual to proctor
this physician for a specified
continued on p. 12
11
Privileging basics
continued from p. 11
number of cases. The proctoring physician would
be compensated for his or her observation activities. Under these circumstances, the individual
would not have to be made a member of the medical staff, as he or she would not engage in patient
care but would observe patient care and render a
report to the MEC or the appropriate department
chair for consideration. Such individuals are available, and if the institution should decide to assume
the burden for such proctoring, this would be an
acceptable solution.
3. The institution could require that the physician
obtain the services of another physician to either
assist or monitor his or her work for a determined
period of time or a determined number of cases.
The entire burden for such proctoring could be
placed on the physician, at his or her expense.
This would be as a condition of continuing the
clinical privilege for cervical discography or pain
management.
4. The institution could secure the services of a qualified outside expert to review all of this individual’s
cervical discograms for the past “X” months and
render an objective written report concerning the
appropriateness of the clinical work documented in
the record. Such a report could be augmented
through on-site or off-site interviews of selected
medical staff members in a position to provide
information deemed useful in the external review
process.
It is of utmost importance to keep our eye on the target in regard to this question. Clearly, the institution
and the medical staff have questions concerning the
quality of services being provided by this physician.
If the institution cannot determine a mechanism that
will result in the safe provision of these services, the
institution should take steps that serve to protect the
patient.
Medical staffs very often select proctoring or direct
observation of clinical work when they are interested
12
in obtaining more information concerning a physician’s
current clinical competence. If the medical staff has
determined that a physician’s competence is seriously
in question, or if they themselves would not permit a
physician to engage in this practice on them or on a
member of their family, then the institution should recognize that proctoring is an ill-advised approach.
A better approach would be to require that, for a period of time, this physician have an assistant for the performance of all of these procedures.
The presence of an assistant serves to more directly
protect the patient, as the assistant will unlikely engage
in patient care activities that are potentially injurious.
The responsibility for obtaining the assistant would fall
clearly on the physician as a condition for exercising
his or her privileges on a continuing basis.
Q: If an anesthesiologist wants to perform pain
management procedures such as placement of
epidural spinal cord stimulators and placement of
intrathecal catheters, what type of additional training would he or she need?
A: A physician who wishes to engage in the activities
defined above should have residency-type training
involving the specific procedures in question.
He or she should also have clinical experience in these
areas, either from the residency program or from postresidency experience. If the residency training occurred
some time ago, the individual should demonstrate
recent clinical experience in performing the procedures
outlined in this question.
Require such a practitioner to obtain references from
knowledgeable individuals who can and will attest to
his or her current clinical competence in this area.
Absent formal residency training (or, post-residency
training acceptable to the credentials committee) and
evidence of recent clinical experience in addition to
references from knowledgeable individuals, the practitioner should not be permitted to apply for these
privileges.
Hugh Greeley Responds: Volume I—Credentialing Concerns
Managed care credentialing
Primary-source verification and other credentialing
basics
Q: I am employed by an NCQA-certified CVO and
have a question about hospital verifications. It’s
not clear in the NCQA language whether it is okay
to receive verbal verification from hospitals. Of
course, when I say “verbal” I mean speaking with
someone in the medical staff office and notating
that person’s name, the date and time of the call,
and exactly what that person told me. What is
your opinion?
A: Generally, an organization may rely on a contemporaneous note as confirmation of information used in
the credentialing process. You state that when you
speak with someone in another medical staff office,
you note that individual’s name, the date, time of the
call, and exactly what was relayed to you. This note
should serve to provide the information necessary to
the credentials committee without requiring the individual to put it in writing.
If you receive negative information in this manner, I
suggest that you immediately turn that information into
a specific questionnaire and send it, with an appropriately executed release, to the individual who initially
provided you with the negative information.
In general, when an institution moves to core privileges, it is not necessary to “back up” core privileges
with an extensive list defining what is in the core in all
specialties. It would, however, be necessary to back up
a core set of privileges with a more detailed list of
areas where procedures are performed. Hospital staff
must have a mechanism permitting them to monitor
whether or not a physician is scheduling procedures
according to his or her clinical privileges. Such a list
need not be made part and parcel of the core. A list
defining (for nursing or operating room staff) what is
in the core can simply be provided to them in a policy
manual.
I realize that this seems to negate the value of the core
privileging process. Actually, it doesn’t. Moving to a
core permits individual physicians to request privileges
Hugh Greeley Responds: Volume I—Credentialing Concerns
in a more rational manner. It is the institution’s responsibility to understand what privileges generally fall
within the core and make such information available to
staff for monitoring a physician’s adherence to his or
her clinical privileges.
It absolutely is not necessary to back up core privileges
in emergency medicine with a list of all emergencies
that may occur or all procedures that could be performed in that area.
Q: We are an NCQA- and URAC-accredited managed care organization (MCO), responsible for credentialing/recredentialing hospitals, home health
agencies, skilled nursing facilities, nursing homes
and free-standing surgical centers. Do you have
any information or recommendations on the best
practice for credentialing these entities? Do you
recommend that the information we gather be primary-source verified?
A: Consider amending your credentials policies and
procedures to incorporate the “new credentialing standard.” (For more information about the “new credentialing standard”, visit www.credentialinfo.com.) There
is very little question that hospitals and other organizations should strive for the very best background information concerning all physicians they permit to practice within their facility. It is also my belief that the current NCQA and JCAHO standards, while representing
excellent initial benchmarks, do not quite go far
enough in today’s complex environment.
Researching a physician’s criminal past, drunken driving record, federal warrants, and arrests records, as
well as obtaining well-drafted professional references
concerning clinical competence and overall professionalism, is essential if an institution is interested in carefully evaluating all potential applicants.
Q: We credential MDs, DOs, and DDSs. What other
providers should be scrutinized at this level (i.e.,
physician assistants, nurse practitioners, or social
workers)?
A: The NCQA requires that all
continued on p. 14
13
Managed care
continued from p. 13
individuals listed in an MCO’s provider manual must be
subject to a credentialing process. The NCQA’s
required credentialing process is not synonymous with
the credentialing process in an acute care hospital. The
NCQA requires the verification and evaluation of information concerning the provider’s background,
education, training, license, claims history, etc. prior to
listing a physician in the provider manual.
If an MCO contracts with a physician who employs
nurse practitioners (NPs) within his practice, but the
NPs will not be listed in the provider manual, the MCO
does not have to specifically evaluate the qualifications
and duties of the NPs. The contract that the MCO
enters into with the physician should cover the physician and his or her employees working under his or
her direct supervision.
Q: The NCQA requires that facilities recredential
every 36 months. If I send out reappointment
applications, then send out a second application
and still don’t get a response, how would I be able
to meet this standard? Does documenting the
attempts suffice?
A: No, the NCQA clearly requires that physicians
appointed to a managed care panel be recredentialed
every 36 months. If a physician fails to complete the
appropriate reapplication forms, his or her appointment to the panel simply expires at the end of the initial 36-month appointment period. The physician is no
longer on the panel and therefore would no longer be
subject to the 36-month recredentialing requirement.
If the physician wants to remain on the panel, it is his
or her responsibility to complete the forms submitted
by the MCO. The credentialing staff that diligently
sends out reapplication forms well in advance and follows 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 physicians to reapply with the requirement that physicians
appointed to an MCO panel be recredentialed and
reevaluated every 36 months.
This issue is exactly the same within an accredited
acute care hospital. Nearly all sets of medical staff
14
bylaws as well as relevant JCAHO and American
Osteopathic Association standards require that appointments be no longer than 24 months. If a physician fails
to complete the appropriate reapplication forms, the
physician’s reappointment should expire at its normal
expiration date. I do not, in any instance, recommend
that an institution maintain a physician on its medical
staff if that physician has not requested reappointment
to the staff.
A distinction should be made here between the physician who reapplies within an appropriate time period
and the physician who fails to complete appropriate
reapplication forms. A reapplication that is legitimately
delayed in processing could result in the granting of a
temporary appointment to the staff (reappointment)
and a temporary grant of privileges pending completion of the entire reapplication process. The physician
who reapplies is simply no longer associated with the
facility. Letters accompanying reapplication should
clearly establish the effect of noncompliance with the
reapplication process.
Q: We are a physician-hospital organization that
performs credentialing/recredentialing. If you
have an automated system in the physician’s
office during normal business hours, does the
NCQA require that the system provide you with a
live person instead of voice mail?
A: No, the NCQA does not require that you provide a
live person.
Q: Regarding physician credentialing standards,
will you please define “gap in work history”?
NCQA standards address gaps of more than six
months. My credentialing department processes
physicians to meet both JCAHO and NCQA standards (for the hospital and the independent practice association), and I want to develop a blanket
policy that will cover gaps.
A: I believe that when a gap appears on an application
or reapplication of longer than one month, the institution should attempt to verify the activities of the physician during that time period. I don’t find compelling
logic with the NCQA’s requirement that the gap be
Hugh Greeley Responds: Volume I—Credentialing Concerns
defined as six months. A physician with a work history
gap of only one month could have, during that month,
participated in a drug rehabilitation program, served
time in jail, or been sanctioned from the Medicare program. You can require a physician to provide a written
and verifiable description of his or her activities during
a reasonably short period of time.
Q: Please answer the following questions:
1. Can we request primary verification from the
various data sources prior to providers returning
the credentialing or recredentialing applications?
2. Is documentation accepted by the NCQA if the
documents are no more than 180 days old at
the time of committee review and approval?
A: A “double yes” to these questions. It’s appropriate for
an organization to verify various pieces of information
prior to the receipt of a recredentialing application. As
long as information is no more than 180 days old prior
to credentials committee review, the early verification of
such information will be acceptable to the NCQA.
Q: Is it essential to solicit information from peers?
We do not employ physicians; we contract with
them.
A: In general, MCOs should solicit information from
peers prior to entering into an employment contract
with physicians. Information concerning licensure, education, training, past practice, and reputation in the
health care community, to name a few factors, is certainly useful. However, this information alone does not
indicate current clinical competence. Only information
received from individuals within the general clinical discipline verifies the practitioner’s current clinical ability.
A peer for an MD is an MD (not necessarily someone
in the same specialty). A DPM would be a peer to a
DPM, a nurse-midwife would be a peer to a nurse-midwife, and so on. MCOs should not limit themselves to
the acquisition of any specific sets of information concerning the qualifications and competence of practitioners wishing to join the MCO’s panel.
MCOs should use policies that provide them with a
great deal of flexibility, permitting them to acquire information not only from peers but also from other indiHugh Greeley Responds: Volume I—Credentialing Concerns
viduals who are qualified to comment on a practitioner’s abilities.
Q: Should all referrals outside the health maintenance (HMO) network be credentialed? If so,
how do you do this?
A: Usually, an MCO should know to whom its patients
are being referred. The “credentialing” of these individuals should establish that the MCO knew that the referral
was made and knew the qualifications of the individual
to whom the referral was being made.
Because not all individuals to whom a patient might be
referred will be listed in the provider manual, it is technically not necessary (under the NCQA standards) that
such individuals be “credentialed” through the MCO’s
credentialing process. The MCO should know to whom
its patients are being sent, for what purposes, and
under what financial arrangements.
The MCO has an independent duty to credential those
practitioners who contract with it. (Harrell v. Total
Health care, Inc., 781 5,w.2d 58 Mo. 1989. See also
Schleier v. Kaiser Foundation Health Plan, 876 f.2d.
174C D.C. App. 1989, where the involvement of a consulting physician with no contractual relationship to the
HMO was sufficient for a jury to render a verdict of
$825,000 against the plan.)
Q: Are diagnostic and treatment centers required
to query the NPDB? The NPDB states in order to
query you must have a formalized peer review
process in place. Can you define what is considered a formalized peer review process?
A: Organizations granting clinical privileges and/or
medical staff membership are strongly encouraged to
contact the NPDB prior to the granting of such clinical
privileges. If you are unclear as to whether your organization would qualify as a formalized peer review entity, you should contact the NPDB and obtain a list of its
prerequisites.
Generally, however, any organization with a formalized
or documented peer review program and a credentialing program resulting in the granting of clinical privileges would be considered a peer review entity for
continued on p. 16
purposes of accessing the NPDB.
15
Managed care
continued from p. 15
More important is that the NPDB may have information
that would be useful to the operation of diagnostic/
other treatment centers.
The databank information could certainly be useful, as
could the information that is readily obtainable from
the American Medical Association Department of
Credentialing Support Products (312/464-5310).
Q: How important is it to have copies of DEA certificates for practitioners who practice in more
than one state? We are a network credentialing
organization and have associated facilities in two
states. Do we need copies of DEA certificates for
both? The DEA wouldn’t sanction a license in only
one state, would it?
A: Hospitals and medical centers permitting physicians
to order certain types of pharmaceuticals must ascertain
that the physician has a valid DEA certificate. If the
institution has physicians on its staff who practice in
more than one state, it’s sufficient for the institution to
verify DEA status one time.
You do not need multiple copies of the DEA certificate.
If the state issues its own certificate permitting physicians to order certain types of medications, then the
medical center or hospital must verify the physician’s
possession of the required certificate in any and all
states in which the physician will be prescribing such
medications. The last component of this question is
answered as follows: The DEA will generally not “sanction” a physician’s certificate in only one state.
Q: We are a medical staff office (MSO) for a single
specialty reaching several states. During employment screening, can we query the NPDB and verify licensure without a signed release? We don’t yet
have these two items incorporated into our hiring
policies for physicians because credentialing is
new to our organization. Should we incorporate
this into our policies or have a separate policy for
16
physicians?
A: The answer to this question is complex, and the
institution’s final policy should be reviewed by a health
care legal expert.
Usually, MSOs are not considered qualified peer review
entities for purposes of the Health care Quality Improvement Act of 1986. As such, they would not be
authorized to query (on their behalf) the NPDB. If an
MSO has been designated as an agent for an authorized
peer review entity and is querying on behalf of that entity, it would certainly be able to make databank queries.
A physician should be required to sign a specific
release authorizing a credentials agency to verify his or
her past education, training, experience, and clinical
competence. Such authorization also should apply to
any other query made to evaluate the physician’s past
performance. This would include databank requests,
malpractice verification queries, disciplinary action
queries, and all other types of information deemed relevant in the credentialing process.
Any MSO policy concerning the mechanisms used to
verify the background, education, training, experience,
and current clinical competence of a physician should
be well documented. Whether this policy is part of the
normal policies concerning employment screening or a
separate policy applying physician employees is up to
the individual organization.
However, we generally recommend that organizations
participating in the phase one or phase two components of the credentialing activity have thoroughly
detailed policies and procedures addressing the mechanisms used to collect, verify, store, disseminate, and
analyze information concerning physicians. This would
apply whether these physicians would be employees
of the organization, or whether the organization is
merely performing this activity on behalf of a hospital,
multispecialty group practice, or other organization.
Hugh Greeley Responds: Volume I—Credentialing Concerns
Allied health professionals
Clinical privileges/temporary privileges
scope of practice or job description?
Q: Should health care organizations delineate clinical privileges to all allied health professionals
(AHPs)? How detailed should the delineation be? Is
the supervising or employing physician responsible for determining what dependent AHPs do?
A: That is a decision each hospital must make. There
are no hard and fast rules, but the following will generally hold true:
A: The hospital should outline a scope of practice for
all of its practicing AHPs. For some AHPs, that may be
the clinical privileges that they have been granted. For
others, it may be a job description. The description
should be specific enough to establish clearly the limits
of the practitioner’s practice within the hospital.
Although a supervising or employing physician may
determine what an AHP can do in any given clinical
situation, the scope of practice for a particular type of
AHP is entirely up to the individual hospital. So an employing physician may not order his or her physician
assistant to perform a procedure that the hospital excludes from a particular scope of practice.
The hospital’s policies and procedures should state that
the supervising/employing physician accepts responsibility for making sure his or her AHPs are not exceeding the hospital-approved scope of practice.
Q: How long should you grant temporary privileges to an AHP? I have a note that states 90 days
is the time period and that you must never give an
extension.
A: A better question is, “Why grant temporary privileges to an AHP?” If you do, your policy should indicate the period during which temporary privileges may
be exercised. Hospitals often establish 90 days as the
period during which temporary privileges may be exercised. Your hospital is free to define the time period.
It’s more important to consider the various pressures
forcing you to grant temporary privileges to AHPs.
Q: Which AHPs should be granted clinical privileges, and which should practice according to a
Hugh Greeley Responds: Volume I—Credentialing Concerns
• AHPs who are independent contractors are granted clinical privileges
• AHPs who provide services, either as an employee
of a physician or the hospital, function according
to a scope of practice or job description
There are exceptions to every rule, however. For example, a hospital may employ nurse midwives to provide services in a prenatal clinic under the supervision
of a physician appointed to the medical staff, but it
may determine that the nature of the nurse midwives’
practice requires a detailed delineation of clinical privileges. On the other hand, a hospital may determine
that a scope of practice is sufficient for physical therapists who provide services in the hospital as independent contractors.
The important point is that the credentials committee
should recommend the scope of practice or delineation
of clinical privileges, whichever is the most appropriate
for a particular class of AHP. The board must then
decide whether to allow that particular class of nonphysician practitioner to practice in the hospital or the
hospital’s facilities.
Q: A privately owned ambulatory surgery center
opened in a small rural city. Appropriate specialty
privileges and criteria were developed with the
exception of oral surgery and podiatry.
Can the governing body of the surgery center
make the decision not to grant privileges to podiatrists and oral surgeons—or other surgical specialties as a group—without creating an antitrust risk?
If so, on what criteria can such a decision be
based?
A: In general, institutions are free to continued on p. 18
17
Allied health
continued from p. 17
determine those services they will or will not provide.
If a surgicenter decides it is not going to offer podiatric
services, then that institution shouldn’t process applications from podiatrists. There need be very few criteria
upon which such a decision is based. The position of
the board of directors concerning the scope of services
provided at the surgicenter should dictate the types of
practitioners eligible for such clinical privileges.
It seems, however, that this surgicenter allows orthopedic surgeons and other physicians to perform certain
procedures on the foot or ankle. If so, it is probably
unwise for the board to determine that the surgicenter
does not provide podiatric services, since it certainly
does. It would be better for the board to determine
those types of practitioners it will or will not permit to
provide services within the surgicenter itself. In the
absence of a nondiscrimination statute within the state,
it is likely that the board of a surgicenter would be
able to determine, on its own, those types of services
that would be provided and the types of practitioners
permitted to do so.
Q: Is it necessary to query the NPDB for AHPs?
A: It is necessary to query the NPDB for any individual
to whom you will be granting clinical privileges.
Therefore, if you grant clinical privileges to an AHP, it
is necessary that you query the NPDB.
This is one of the reasons we recommend not granting
clinical privileges to most AHPs but allowing them to
practice according to a scope of service or other written
agreement. Remember that most AHPs are not licensed
independent practitioners (LIPs) practicing without supervision. It is only those individuals who must have
clinical privileges.
Medical staff office v. human resources
Q: How are the issues of competence being addressed for AHPs? The medical staff office (MSO)
has a much more thorough credentialing process
than that of the human resources office. Some
hospitals are transferring the AHP credentialing to
the HR office as the JCAHO is saying that the
process for all AHPs must be the same whether
18
the AHP is an employee of the hospital or not.
A: In this question, the word “credentialing” is used
inappropriately. Specifically, the medical staff office has
a much more thorough verification process than that of
the human resource office. It is important to recognize
that the term credentialing means nothing unless otherwise defined within an individual organization. For
purposes of this question, we will break the term credentialing down into its three fundamental phases:
Phase one: information gathering, verification,
storage, dissemination
Phase two: Review and evaluation of collected
information
Phase three: Decision-making
In light of these three phases, the medical staff office
does not credential AHPs. The medical staff office or
the human resource department simply conducts
phase one activities. Phases two and three must be
conducted according to institutional policy. Such policy could, as indicated above, involve medical staff
committees, medical staff officials, or representatives of
management.
Phase one activity must be done well, regardless of
which office does it. There should not be a circumstance under which one office does it better than the
other. It is certainly possible for a human resource
office to engage in phase-one verification activity. It is
also likely that a medical staff office could conduct this
activity appropriately.
The second part of this question relates to the JCAHO.
Apparently, the questioner believes that the JCAHO
requires that the credentialing process for all AHPs
must be the same, whether the AHP is an employee of
the hospital or not. This is not true; there is no such
JCAHO standard. The JCAHO does require that all individuals providing care within the hospital must be considered competent through a defined process. An
employee could be considered competent through a
process involving the human resource department. In
an equally efficient manner, a nonemployee, in the
same discipline, could be found competent through a
process involving the medical staff office and/or repre-
Hugh Greeley Responds: Volume I—Credentialing Concerns
sentatives of the medical staff. The outcome must be
the same, not the process.
Q: A JCAHO surveyor suggested that we move our
AHPs from the medical staff to the human
resources department. Her reasoning was that our
bylaws include no provision for a fair-hearing
process for AHPs. Should we have such a provision in our bylaws? If not, why should we move
our AHPs under human resources?
A: The JCAHO requires that individuals with clinical
privileges, whether medical staff members or not, be
granted some form of hearing if the hospital takes corrective or disciplinary actions that affect those privileges. The JCAHO makes it clear that the “fair hearing”
mechanism given to nonmedical staff members need
not be as extensive as the mechanism granted to physicians. If your medical staff bylaws or associated documents do not contain a provision for giving an AHP
some type of a fair hearing, you should amend them to
include such a provision.
The above applies only if the institution actually grants
clinical privileges to the individual AHP. If the hospital
permits the individual to provide clinical services under
supervision, according to a job description or some
scope of practice, there would be no JCAHO requirement to provide him or her with a hearing if their permission to practice were revoked.
If a JCAHO surveyor suggested that you move your
allied health staff to human resources from the medical
staff, he or she was simply providing you with a consultative recommendation and not referencing a specific JCAHO standard.
Individuals working under defined supervision should
not be granted clinical privileges unless they are to
become members of the medical staff.
Provide them with an agreement, scope of practice, or
other document authorizing their work within the facility. The rationale for this recommendation is as follows:
• You might easily avoid the necessity of providing
these individuals with a full-blown fair hearing.
• You will eliminate any confusion over whether or
not these individuals are part of the medical staff.
Hugh Greeley Responds: Volume I—Credentialing Concerns
• The grant of authority to these individuals to provide patient services need not require medical
executive committee or board review.
• Authorizing such individuals to practice under
defined supervision is usually much simpler than
going the “privileging route.”
• Most providers in the AHP category do not maintain an independent license, and nearly all practice under defined supervision. (Under current
JCAHO standards, there is no compelling reason
to require these individuals to be granted clinical
privileges.)
And obviously, it is very important for the institution to
conduct a thorough evaluation of each practitioner’s
ability to provide clinical services, regardless of
whether he or she requires supervision. Patient care
and safety must always come first.
Q: You have recommended that the human
resources department credential LIPs practicing
with defined supervision. Can you please define
what type of practitioners you are referring to?
A: I recommend that the human resources department
process anyone who is employed by the organization.
If the institution is employing someone who will also
be a member of the medical staff, the individual must
acquire clinical privileges through the mechanism
defined within the medical staff bylaws.
LIPs practicing with defined supervision are just that—
individuals licensed by the state to practice independently according to a job description, policy, protocol,
scope of practice, or other document defining the
required supervision. If the MEC determines that the
type of supervision is sufficient, that individual may
receive permission to provide services within the
organization through a route that does not necessarily
include the MEC.
The human resources department must have some
involvement in the processing of AHP applications.
These individuals must, in fact, fill out employment
applications; be subject to annual performance evaluation; and work with the human resources department
to fulfill their orientation, continuing education and
inservice requirements, health requirements, etc.
Whether your institution chooses to continued on p. 20
19
Allied health
continued from p. 19
have these individuals’ qualifications reviewed by officials of the medical staff, including the executive committee, is your own decision. You have a lot of flexibility
when it comes to defining the processing route for individuals who will not be appointed to the medical staff.
Q: Two years ago, we changed our AHP credentialing process from one facilitated entirely by the
medical staff office to an interdepartmental
process including human resources, nursing, and
the hospital education departments. We designed
this process to try to treat our AHPs in a similar
manner as their hospital counterparts.
The departments other than the medical staff
office want us to enforce a mandatory yearly safety education update and age-specific competency
assessments. My opinion is that this is overkill.
How far how should the hospital go in trying to
treat AHPs the same as employees?
A: I congratulate you for moving the credentialing
process for AHPs to a more interdepartmental process
including human resources, etc., as it is a more effective way to permit AHPs to provide services within an
acute care hospital.
I also agree with you that it is not necessary for these
“nonemployees” to participate in an annual safety education update and age-specific competency assessments. I do, however, believe that all individuals who
work within the hospital, whether employed or not,
should have material concerning safety, infection control, sexual harassment, etc. You are correct: You
redesigned your process in an attempt to make life easier for the employees of physicians, and since all of
these individuals are being supervised directly by their
physician employer, it isn’t necessary that they participate in age-specific competency assessments.
You should, however, require that the physician
employer complete an evaluation to include in the
AHP’s file on an annual or biannual basis. This need
not be complex, but it should indicate that the physician continues to believe that
• his or her employee has good skills
20
• his or her employee good judgment
• his or her employee has an adequate overall professional performance
Further, the physician must understand that the AHP is
working under his or her direct supervision; that his or
her insurance policy provides coverage for the acts of
this individual; and that the physician retains the overall responsibility for all actions of his or her employee.
AHP supervision
Q: Who should supervise AHPs?
A: If the hospital grants AHPs permission to practice
within its facility, it has a duty to supervise their work.
Such supervision can be performed through the relevant department chief, supervising/sponsoring physician, or other appropriate hospital supervisor. Hospital
policies on AHPs should specifically indicate who will
supervise each class of AHP allowed to practice in the
hospital and how that supervision will be done.
The same supervision policies that apply to hospital
employees should cover all AHPs (and physicians).
The medical staff quality improvement system (and
specifically, department chiefs) handles supervision of
physicians appointed to the medical staff. The relevant
manager and the department of human resources
supervise employees. The hospital must supervise
AHPs (meaning nonemployees, nonmedical staff members) in a similar manner.
Legally, all members of the medical staff could be
required to participate in supervision. All agree, as a
condition of medical staff appointment, to accept reasonable assignments. However, that does not always
work. A new practitioner, such as a nurse-midwife or
certified registered nurse anesthetist, may receive permission to practice subject to his or her obtaining the
written agreement of an individual appropriately qualified to supervise.
Q: We are a behavioral health facility. Is there such
a thing as privileging without supervision and
privileging with supervision, and would the RNs
and LPNs come under the “with supervision”
heading? Do the RNs have to be privileged for
Hugh Greeley Responds: Volume I—Credentialing Concerns
everything they do in their job description?
A: Employed LPNs and RNs do not need to be privileged at all. They are generally permitted to practice
by a job description and are under the constant
supervision of nursing directors or other nursing managers. If a particular individual possesses a needed
skill that is not possessed by other RNs or LPNs, the
institution can permit this individual to perform this
skill as long as it is within the scope of his or her
license. No privileging is necessary at all. I generally
recommend that clinical privileging be reserved for
individuals who will be practicing independently without supervision.
Appointment and reappointment
Process and paperwork
Q: Is it correct that the credentials file should
go to the department chief for review after all
primary-source verification is completed? After
that, should it then go to the MEC for review,
and to the board of trustees for recommendation? Could temporary privileges then be granted while waiting for board approval?
A: The medical staff appointment process should proceed 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 recommends 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 or
red flags, a designated subcommittee of the board (ideally composed of the hospital’s CEO, chief of staff, and
credentials committee chair) can review and grant final
approval. Such a subcommittee would report its actions
regularly to the entire board.
JCAHO standards give the nod only to a board subcommittee—nothing is stated with regard to the credentials committee or the MEC.
Hospitals must write the use of a board subcommittee
into its medical staff bylaws, as well as into its credentialing policies and procedures manual.
Hugh Greeley Responds: Volume I—Credentialing Concerns
As for temporary privileges, in March 2002, the JCAHO
released a clarification that makes it clear that organizations can only use them when it involves an urgent
patient-care need or when an initial applicant with a
complete, clean application is awaiting approval of the
MEC and governing body. Organizations cannot grant
temporary privileges to combat administrative delays. If
an effective expedited credentialing system is in place
(as outlined in the two preceding paragraphs), it should
eliminate the pressure for temporary privileges in the
first place.
Q: During the approval process for appointment
and reappointment, is it necessary to obtain the
signatures of the president of the medical staff
and the chair of the board?
A: No, it is not necessary to obtain signatures on applications or reapplications forms reflecting the approval
of the medical staff president and/or the chair of the
board. The minutes of appropriately organized committees reflect the approval of the MEC and the board.
An MSSP or other designated individual may stamp the
application and reapplication in the appropriate spot to
indicate that approval is documented in the minutes of
the (specified) committee on such-and-such a date. The
secretary to the board may always sign appropriate
documents for the board chair reflecting board actions
(provided such actions are documented within the
minutes).
Q: Is there a standard regarding the use of electronic signatures on credentialing forms?
A: I am not entirely sure why one
continued on p. 22
21
Appointment and reappointment
would use an electronic signature on a credentialing
form. However, if your institution permits physicians to
authenticate patient records via electronic signature, a
policy could be established permitting physicians to
authenticate medical staff applications the same way.
Perhaps your organization uses an “electronic” application that a physician can complete and submit via
his or her computer. It is, however, my recommendation that, in the absence of an electronic application,
applicants and reapplicants must be required to attest
to the accuracy and completeness of their credentialing forms via standard, handwritten signatures.
Q: When a physician applies for reappointment
to our medical staff, we ask him or her to provide information regarding professional liability
claims, either pending or settled, over the past
two years. We also write directly to the insurance
company to verify coverage and to obtain claims
history information. Do we really need to take
this step? I have talked to several hospitals that
take the word of the physician and do not verify
the information. Is that appropriate?
A: Your hospital is correct in verifying insurance coverage and claims history. Simply taking the physician’s
word for it is no longer sufficient. It is absolutely necessary that hospitals verify all information collected
during the application and reapplication processes.
Q: I oversee the credentialing process at a longterm care (LTC) facility. Our parent organization
owns two LTC facilities on one campus, each
with its own LTC license and administrative staff.
The department of health surveys each individually. Could we use one set of credentialing
records (applications and verifications) for both
LTC facilities, or must each facility receive a separate application/questionnaire/release and verifications records from the physician? Again, both
facilities are owned by the same organization and
share the same list of attending physicians.
A: You may absolutely use one set of records, applications, and verifications for both facilities. The only
exception to this rule is the NPDB report. If your
facilities maintain separate access numbers for the
22
continued from p. 21
NPDB, you must acquire a NPDB report for each facility. If each of your LTC facilities is considered a single
provider by the NPDB, you may then access the NPDB
report once and use it within both of your fully owned
facilities.
I recommend that your applications and reapplications
indicate that they apply to both facilities specifically.
Because your institutions are separately licensed, it is
necessary for the organization’s board to appoint and
reappoint physicians to both facilities (i.e., “We the
board appoint Dr. William Smith to facility A and to
facility B.”).
Q: At our facility, if the credentials committee has
concerns about an applicant’s appointment or
reappointment, they inform the MEC for further
input. The MEC then follows the issue for a month
or more and then makes a final recommendation.
Under these circumstances, does the applicant
need to be re-reviewed through the credentials
committee, or is it okay to simply forward a recommendation to the governing board?
A: Yes, it is okay. The MEC need not refer the issue
back to the credentials committee, but should make its
recommendation to the governing board for a final
determination.
Q: I recently heard that the JCAHO requires the
signature of only the department chair/division
chief on a reappointment application, and that
minutes of the credentials committee, MEC, and
board of trustees need to reflect only action taken
on the reappointment application. Is this information accurate?
A: Actually, the JCAHO does not require a “signature”
on any specific document. It does require that the department chair conduct an evaluation and make a recommendation concerning any individual applying for
clinical privileges within the department. The department chairperson could document his or her evaluation
and recommendation in a number of ways. The most
common way is by completing a carefully designed
form in which the department chair indicates his or her
assessment of the applicant’s education, training, expe-
Hugh Greeley Responds: Volume I—Credentialing Concerns
rience, current competence, ability to relate to others,
adherence to bylaws, and other indicators of continuing qualification. Certainly the department chairperson
is not “required” to sign the application or the reapplication.
If the application and reapplication contain a signature
block for the department chair, he or she certainly should
use it to document his or her assessment and evaluation.
The same general logic is true for the credentials committee, MEC, and board. The Joint Commission does
not require the signature of a credentials chair, chief of
staff, or board member on the application itself. It
requires the MEC to formulate a recommendation for
consideration by the board, and requires the board to
make a decision to appoint and/or grant clinical privileges. Such a decision could be memorialized in the
board minutes, a separate board report, a specific form
designed just for that purpose, or by a board member’s
signature on the application itself.
In responding to this question, it must be stressed that
the JCAHO expects a fairly comprehensive evaluation of
an individual physician’s qualification for appointment
and/or clinical privileges. A signature on a form attests
to nothing unless it is preceded by documentation of a
careful and methodical evaluation of clinical judgment,
technical skill, and overall professional performance.
Policies and forms
Q: Our credentials committee is conducting an
annual review of the form letters we send during
the initial medical staff appointment process. One
committee member suggested adding the following questions to the training form, the peer reference form, and the hospital affiliation form. They
are as follows:
#2 as follows: “If your specialty group were searching
for a new physician, would he or she be a viable
candidate for employment or recruitment?” Question
#3 is probably not appropriate because physicians
generally base their “family physician” choices on a
wide variety of factors, many of which are independent of competence issues.
A better question might be, “Would you be comfortable having a neighbor or friend treated by this
physician?” You certainly could add these questions
to your forms, and you will probably receive relatively straightforward information as a result. Most applicants have no problems in their practice backgrounds
and enjoy the confidence of their colleagues.
Q: Do you have samples of questions to ask during the clinical interview that focus on patient
care issues?
A: You should base questions for the clinical interview (if held) on the applicant’s specialty and background. I recommend that you break them down
into three components:
1. Questions needed to “flesh out” the application
itself. Such questions seek further information
about omissions in the application, obvious
errors, potential falsifications, etc.
2. Questions concerning the applicant’s intended
practice plan for the institution. Such questions
would range from, “How do you anticipate helping the institution and medical staff with its mission?” to “Do you agree to provide emergency
backup when requested by the emergency
department ED physicians?”
Are these questions appropriate?
3. Clinical questions designed to “test” the applicant’s current knowledge, judgment, and skill.
Such questions would obviously vary by specialty. You could quite easily phrase them as follows:
“Please describe a recent interesting or complex
case in which you were the primary physician.
Describe your workup, diagnosis, use of consultants, etc.”
A: Question #1 is excellent. You might reword question
Use an interview form to capture the continued on p. 24
1. Would you be pleased to have this doctor stay
and practice in your community?
2. Would you have this doctor join your group?
3. Would you take your family members to this
doctor?
Hugh Greeley Responds: Volume I—Credentialing Concerns
23
Appointment and reappointment
general nature of the questions and the responses. It is
not necessary to keep a detailed account of all questions
and answers.
Q: What is the best type of form to use when a
physician comes back to work from an injury or
illness?
A: Unfortunately, the answer to this question is far
more complicated than the use of a form. It depends
on a number of things:
1. Was this a formal leave of absence? If so, the
bylaws or a policy should indicate what should
happen to reinstate the physician after a leave of
absence.
2. What was the term of leave? Thirty days? One year?
Consider where the physician was in the reappointment cycle. Generally speaking, leaves of absence can
be granted for up to two years, depending on the situation. If the leave is for one year or more, many hospitals
require a new reinstatement application. If the reappointment expires during the leave, the hospital should require the physician to complete the full reappointment
application as part of reinstatement.
Q: We are a semi-urban hospital of approximately
200 beds and 500 physicians on staff. Most of the
physicians routinely complete their patient records within an appropriate time period, but three
consistently do not. Our MEC is reaching the
breaking point on this issue. The three physicians
have been brought before the MEC six times over
the past two years. In each of these sessions, the
MEC seems quite purposeful in suggesting that
they mend their delinquent ways and complete
their records, but invariably, the three physicians
relapse and delinquent records continue to mount.
02/03
continued from p. 23
What might our MEC contemplate?
A: The MEC has many options at this point. Based upon
our research with the institution that asked this question,
it is clear that this executive committee has the courage
necessary to tackle this issue. They have, in fact, dealt
with more difficult issues in the past. I suggest the following recommendations for consideration by this MEC.
The MEC might consider passing a self-enforcing policy
regarding medical records completion. Its current policy indicates that a physician who does not complete
his or her records within a defined period will be suspended. While on suspension, the physician’s clinical
privileges to admit or schedule surgery are also suspended. The MEC might consider adding to this policy
a provision that says a physician whose name appears
on the suspension list six times in a 12-month time
period will automatically lose medical staff membership
and all clinical privileges. Such physicians will be
allowed to apply to rejoin the medical staff, but first
will be required to interview with the credentials committee and the board of directors to explain how they
plan to complete their records in a timelier manner.
Such automatic termination of appointment and privileges (which will take place after the discharge of the
physician’s current patients) will not be subject to a fair
hearing and appeal process.
The MEC might consider passing a policy indicating
that physicians who have been on the suspension list
more than three times in any calendar year will be
fined $10 per delinquent chart per day, in addition to
automatic suspension for failure to complete records. The
physician should also be informed that he or she would
be ineligible for reappointment unless all fines are paid.
The chief of staff could appoint these physicians as the
permanent members of the medical records committee
with a requirement that the committee meet weekly until
the problem of incomplete records has been solved.
SR603
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