Run a gap analysis’ to fix problems
We’re seeing a major paradigm shift’
Consider this scenario: Your organization claims to have a good, Medicare-compliant system in place. Yet you see at the Internet site of the Office of the Inspector General (OIG) that one of your physicians has been excluded from participating in Medicare as a result of disciplinary action by the Health Care Financing Administration, the agency that administers Medicare.
What can you do to correct the situation? Fay Rozovsky, JD, MPH, and Mark Kadzielski, JD, both experts in this area, advise first that you refrain from panicking. Rozovsky is president of the Rozovsky Group, a consulting firm in Richmond, VA, as well as a member of Hospital Peer Review’s editorial advisory board. Kadzielski is head of the West Coast Health Law practice and a partner in the Los Angeles office of Epstein Becker & Green.
"Look at your current credentialing criteria — rules, regulations, bylaws, contracts," says Kadzielski. "What’s in the letter that goes out to someone applying for appointment or renewal? What do the applications say?" The attorneys suggest you assemble a multidisciplinary team within your organization and include medical leadership, your legal counsel, and the heads of risk management, medical staff services, and corporate compliance. Sit down and make sure everyone understands the complexity of the situation. Find out what your compliance plan says about this issue. Does it speak to credentialing?
Kathryn Biasotti, RN, compliance officer and director of risk and quality management at Barton Memorial Hospital in South Lake Tahoe, CA, and Elizabeth Babbitt, Barton’s medical staff assistant, are in the midst of revising their facility’s medical staff bylaws and credentialing procedures to take into account the new compliance-credentialing landscape, as is Judith Wilbur, RN, director, risk management and quality assurance, Fremont-Rideout Health Group, Marysville, CA. "We are looking at the compliance-credentialing crosswalk,’ educating our staff, and beginning to introduce compliance issues to the board," says Wilbur. (See next month’s issue of HPR for an article explaining what these California quality professionals are doing to ensure their facilities’ compliance and credentialing accuracy.)
Rewrite your bylaws so that the requirements of being a medical staff member include Medicare participation as well as compliance with all federal, state, and local regulations, laws, and standards. An important part of new bylaw language should include a physician’s voluntary relinquishment of privileges in the case of any sanction, felony conviction, Drug Enforcement Agency (DEA) violation, or failure to maintain liability insurance. The voluntary stipulation is important because if privileges are relinquished voluntarily, the action is not NPDB-reportable. Others will report the action to the data bank, but this way, the physician is not entitled to a hearing, and it’s easier on the hospital — you don’t have to go through the grief of the hearing and appeals process. Using the voluntary language makes dismissal instantaneous.
"The good old days of credentialing providers once every two years for purposes of reappointment are gone," says Kadzielski. He recommends establishing a policy of checking medical staff credentials on specific Internet Web sites on a twice-yearly basis. He says having that policy in place will go a long way to limit your facility’s liability for negligent credentialing.
Run an internal review — a "gap analysis," suggests Rozovsky. "Ask yourselves, What are we saying in compliance that is not copacetic with what we’re doing under the bylaws?’ And vice versa." Set priorities, and deal with them one by one. Consider: If this were to happen, this would be the consequence under the bylaws. But under the CCP, it may be different. How do I bring the two together?
What you discover may mean revising your bylaws, rethinking contracts, and changing the rules and regulations of the medical staff. Your legal counsel’s role in this is to review all contracts and boilerplate and make them "compliance-ready." The attorneys should also review bylaws, make them compliance-ready too, and give you regular legal updates in this volatile arena. You also will have to educate your executive board and medical staff credentialing committee — telling them the rules have changed from what they have been taking for granted for the past 13 years. "This is a major paradigm shift," says Rozovsky.
Regarding medical staff bylaws, Patrick H. Reymann, JD, with Buckingham, Doolittle & Burroughs in Akron, OH, says, "A good working document avoids a lot of problems and arms the leadership of the medical staff when someone refuses to follow the rules." Simplifying bylaws does not mean making them shorter, he explains. It means giving them more clarity and more usefulness. (See the upcoming August issue of HPR for an article by Reymann on credentialing allied practitioners.)
Where you start depends on where you’re situated. If you are working at a large academic medical center, you have more databases to consider than just those of Medicare and Medicaid. If you have a research physician who is doing creative accounting and a CCP that says your organization has zero tolerance for that type of behavior, that may merit taking corrective action. You have to check the database of the NIH’s Office for Protec tion from Research Risks ([email protected]) for updates of those physicians. (In next month’s issue of HPR, we report on two California facilities and what sites they check for their credentialing.)
Jackie Kobierecki, RN, sits on the board committee for professional activities that does the credentialing at Affinity Health System in Oshkosh, WI. She says fraud and abuse questions were recently added to Affinity’s standard application for reappointment. "We’ve never had a situation where a physician would answer yes to a question about fraud and abuse," she says, "but if, during an interview, signals are raised — malpractice at another facility or any licensure actions — the doctor is invited to a committee meeting to respond and provide more information."
What do they do when physicians answer no to questions about fraud? "We verify that by checking the Internet sites of the NPDB, AMA, and state of Wisconsin," Kobierecki says. Affinity’s compliance team has the system’s compliance plan in place, she says, but they now have to correlate the plan’s elements with credentialing procedures.
Don’t wait until this problem bites you, advise the experts. Start thinking about these issues and changing the way your staff look at them. Some facilities are further along than others with their CCP, but they may not be ahead in the long run, says Rozovsky. Facilities with a generous budget and a leadership that embraced the concept of compliance early are further ahead in setting up their organizations’ CCPs.
"But it’s just those advance guards who may not have seen these other conflicting issues emerging," says Rozovsky. "Those who are jumping in later may actually have an advantage here. They can build their CCP from the get-go to accommodate credentialing."
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