Here’s how you should straddle the compliance-credentialing crosswalk
Drill down in your credentialing process to cover all the bases
Your credentialing process, now more than ever, must take into account all information on a practitioner — not just education, training, licensure, and clinical competence, but also information regarding Medicare participation and compliance, and past and present judgments and settlements. All that data must figure in the decision-making process.
But your institution’s promise of "zero tolerance for fraud" does not necessarily mean all practitioners with problems must be expelled, says Mark Kadzielski, Esq., a partner in the Los Angeles office of Epstein Becker & Green. What it means is that you will be doing more risk assessments and your organization will be exposed to more negligent credentialing liability than ever before.
A good first step is to educate your credentials committee to ask for nonclinical information on applications and to verify everything. Advise them that they have to access the Internet as part of the credentials check, says Kadzielski, "specifically state licensing boards and the OIG site." Get information on any pending state licensure action from the state licensing board’s site, and access the Web site of the Office of the Inspector General (OIG) — www.dhhs.gov/progorg/oig/cumsan/index.htm — to see if there’s a debarment or judgment on the federal level against an individual.
Ben St. John at the Inspector General’s office says the OIG’s List of Excluded Individuals/Enti ties provides information regarding individuals and entities that are excluded from participation in Medicare, Medicaid, and other federal health care programs. "The various authorities under which they can be excluded from programs cover problems ranging from failure to repay a Health Education Assistance Loan to patient abuse and defrauding a federal program," he says. The sanctions list is issued monthly, and it includes new sanctions as well as reinstatements. About 15,000 individuals and entities are currently excluded.
The OIG’s Web site provides information regarding excluded individuals and entities sorted by the legal bases for exclusion, by category of individual or entity, and by the state where they reside or do business. You can also search the database by name, specialty, city, state, zip code, or sanction type in order to find out whether a specific individual or entity is currently excluded from program participation.
Once you and the committee have all the information, are you able to process it, understand it, and make decisions?
"We need to analyze past malpractice lawsuits against a doctor," says Kadzielski. "Ask some hard questions. Say, for example, Well, he settled most, but all those brought against him had to do with ablation. Maybe he doesn’t do that procedure very well. We ought to take a close look at that pattern.’"
Kadzielski says the malpractice judgment system is an inexact way to judge a physician’s quality. Cases typically take five years, and actions get handled and settled on the basis of many things that have little relation to what really happened.
"Tying fraud and abuse issues to credentialing is going to involve a process change," says Judith Wilbur, RN, director of risk management and quality assurance at mid-sized Fremont-Rideout Health Group in California. The group comprises Fremont Medical Center in Marysville and Rideout Memorial Hospital in Yuba City. Some paragraphs in Rideout’s staff bylaws cover fraud and abuse issues, but "they’re not as specific as they should be for what we should be working toward," she says.
"We are looking at the compliance-credentialing crosswalk, educating our staff, and beginning to introduce compliance issues to the board," Wilbur says. Rideout’s compliance officer has put together a plan that soon will be brought to the medical staff.
"It has always been a part of our credentialing that you have to state if you’ve been convicted of [violations of federal or state law," says Wilbur. "Our disclosure statements specify that." (See details of Fremont’s applications in story on p. 104.) Fraud and abuse issues haven’t been a problem so far during her nine years of credentialing, she says.
Computer queries take 24 hours
How does her staff verify credentials? "We used to do handwritten queries, but now we do computer verification, and queries are turned around in 24 hours. We do an NPDB [National Practitioner Data Bank] search and validate licensures, boards, and schools. We check with the American Medical Association and the Educa tional Council for Foreign Medical Graduates. Once it’s up and running, we’ll go through third-party payers to get at the HIPDB [Healthcare Integrity and Protection Data Bank] information." (See next month’s issue of Hospital Peer Review for an article on the AMA’s American Medical Accreditation Program and the HIPDB.)
Wilbur says Fremont-Rideout has an interdisciplinary practice committee for credentialing phy sician assistants and nurse midwives, and the personnel office evaluates RNs. "We’re responsible as well for credentialing those physicians who are employees," she says. Physicians who are department medical directors are hospital employees, but most doctors are independent contractors.
The Joint Commission and the California Medical Association each has its own credentialing requirements, says Kathryn Biasotti, RN, director of risk and quality management and compliance officer at Barton Memorial Hospital in South Lake Tahoe, CA, but they survey as a team. "They look at medical staff bylaws. Typically, on the last day of their survey, one physician will review the bylaws, and the other will look through physician files to ensure that we really do what we say we do in our bylaws."
Wilbur agrees. "When the Joint Commission team surveys, they look at files and minutes from the credentials meetings, and they check for verification of all the paperwork. They look to make sure the appropriate committee approved the paperwork, and that everyone was notified and that signatures were obtained. They are very thorough and spend a lot of time on credentialing."
Fremont-Rideout was last surveyed in 1997, and the team was there four days. "A physician surveyor from the Joint Commission and a physician surveyor from the state reviewed our credentials files," she says. "Typically, the Joint Commission surveyor defers to the state surveyor for this because the California Department of Health standards are more prescriptive than the Joint Commission’s. They are tougher, more exacting. If you pass muster with the state, you’ll pass with the Joint Commission."
Robert E. Lee, MD, PhD, associate director in the department of standards at the Joint Commission, comments on that: "The Joint Commission expects accredited hospitals to be in compliance with appropriate federal and state laws, rules, and regulations. It’s not a matter of competition. Which ever level is more stringent, that’s the level the Joint Commission expects the facility to be responsive to. In one area, a Joint Commis sion standard might be the highest level; in another, a federal or state rule may be more stringent."
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