we start a new year, century and millenium, it is only fitting that we start on
the credentialing of new applicants and re-credentialing of present medical
is a process of determining whether or not an applicant has the general
qualifications for your medical staff and consists of three parts.
The first is the applicant or re-applicant requesting the application,
filling it out completely and truthfully with all references and returning it to
the Medical Staff Office. The
second is the verification of all required material by the Medical Staff Office. The third and last step is the internal process of reviewing,
with or without interviewing the applicant, and recommending to the governing
body (Board) the medical staff decision regarding the applicant.
The Board makes the final decision regarding medical staff credentialing.
This process is tied to, but is not the same as, privileging.
Privileging is qualification for specific types of procedures or
membership is a privilege and not a right.
Credentialing of applicants and re-applicants are to protect patient
care. If a person holds a license
to practice medicine in California, he/she is not automatically entitled to
medical staff membership. The
burden is on the applicant to furnish the evidence required for medical staff
membership not on the medical staff office to continue to remind the applicant
initial credentialing packet is sent to and received from the applicant by the
Medical Staff Office. If it is a
new application, it can be handled in either the standard manner or under a
“fast track” methodology. This new way allows the application to be reviewed
expeditiously. If there are no
“red flags”, the application is screened by the Department Chair, Credential
Chair, and Chief of Staff and then sent to the Board.
If there is any doubt by any level of review, the application is handled
in the standard manner. The “red
flags” for initial appointment include but are not limited to time lapses in
training, “iffy” letters of recommendations, or out of training for a period
of time and not Board Certified or Eligible.
The criteria for membership are set in advance for all applicants by the
medical staff. This will help alleviate any potential antitrust action. There is
a potential for a lack of checks and balances with the fast track system where a
powerful physician may intercede to
let a non-qualified applicant on the staff. This has apparently happened on at
least one occasion. There have been some recent JCAHO Type I recommendations
given for using this system.
(Since this was written the JCAHO rules have changed to allow fast track as
long as a board committee and not just one person approves the applicant on an
standard method is the application goes through committees and not just chairs.
This requires more time for the committees to meet, but does allow for
more medical staff members to “eyeball” the application. There are now some
new web based technologies that may help speed up the standard credentialing
process. The applicant should not be given even temporary staff membership until
the Medical Staff Office verifies all the basic information and all fees paid.
medical staffs for an initial applicant use a “pre-application” or a letter
explaining the medical staff’s pre-determined minimum objective standards for
membership. If the pre-applicant
answers the questions falsely, does not answer the questions or does not have
the general qualifications required for staff membership they may be rejected
and not be entitled to a Judicial Appeal. If
they pass the pre-application and the application is then denied, the affected
physician is entitled to a Judicial Review on the reasons for the denial. This
will be expensive for both parties. If
they are kept off for competitive reasons, unless exclusive contracts exist,
antitrust concerns may be raised. It is imperative that medical staffs follow
their by-laws exactly or they may be sued for membership.
The Health Care Quality Improvement Act (HCQIA) allows an antitrust suit
but not monetary damages. The courts may allow an injunction against the medical
staff and hospital allowing the applicant on the staff. They may also allow
attorney’s fees, which may be considerable.
Please consult your independent medical staff attorney (paid by the
medical staff, not the hospital).
rule for re-application to the medical staff is that it must be done every two
years. The Joint Commission is very
tough on this. If only one person is not re-credentialed for any reason by
the Board within the allotted time, a Type I violation may ensue. I suggest that
re-appointment packets be sent out well in advance (3-4 months) of the date
needed. It takes considerable time
for the information to be verified, letters of recommendation received and the
slow processes of going through the Department, Credential and Medical Executive
Committees prior to Board action. If an applicant is not through the whole
credentialing process due to no fault of the applicant in the allotted time
temporary privileges may be granted. This
does not take the place of the formal recredentialing process.
credentialing, as defined as credentialing for economic reasons unrelated to
quality or competence, is frowned on by most medical societies. However, where a
physician uses more resources than others, it is possible that they have less
clinical skills and need to be watched closely by the medical staff.
the time of both initial application and reapplication the Medical Board of
California, National Practitioner Data Bank must be queried.
Other queries are for DEA license, Medicare sanctions, and malpractice
insurance. Some hospitals even hire firms to look for any medically related
crimes. References from peers are imperative. These should include one from a medical staff member in the
same field who is not in business with the applicant. An MD and DO may give
references for each other but a DDS or DPM etc. need to be peer referenced.
CME is required by the State for licensure and the Joint Commission wants
to see that the Medical Staff has asked as well.
This may be done by having the physician bring in proof of all CME or by
merely attesting that he/she has enough hours to qualify.
If the latter is chosen, random audits should be done. The educational
hours do not have to be in the person’s specialty.
application and re-application questionnaire should address all the above areas
plus Board Certification status, whether the applicant has been convicted or is
being investigated for Medicare or Medicaid fraud and any health issues that may
preclude the practitioner from performing their clinical duties.
credentialing should be performed for ALL medical staff applicants. If you
believe that you can let one application slide, I recommend highly the book Blind
Eye that describes how a physician was not credentialed properly.
Dr. Swango, the physician in the book, is currently in jail.
He is possibly tied to murders of patients.
credentialing process and its timeline make an excellent continuous quality
improvement project. This may also save the Medical Staff a Type I recommendation
your hospital allows Allied Health Professionals (AHP), they should be
credentialed in the same manner as the medical staff.
Again, references from supervising people are important. The question is
who should oversee the process, the Medical Staff or the Hospital.
If the AHP is hired (employed) by the hospital, the hospital should do
the credentialing. If the AHP
perform clinical work as Licensed Independent Practitioners, they may be
monitored via the Medical Staff. This is an ongoing controversy. It is possible that those physicians doing peer review on
AHPs will not be afforded the protections of the Health Care Quality Improvement
Act. A Committee on Interdisciplinary Practice as required under Section 70706
of Title 22 is a non-medical staff committee that reports to the Board.
Physicians on this committee will probably be protected under the hospital
Please contact me if there
are any topics you wish me to discuss in future editions or if I may be of
service to you and/or your Medical Staff. If
you are no longer the Chief of Staff, please forward this newsletter to that
individual. I would
appreciate if you would ask your Medical Staff Office to send me the
correct name of the new Chief of Staff. Thank you and I hope your new year is
filled with health and happiness.
DISCLAIMER: Although this article is updated periodically, it reflects the
author's point of view at the time of publication. Nothing in this article
constitutes legal advice. Readers should consult with their own legal counsel
before acting on any of the information presented.