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Common Healthcare Provider Credentialing Mistakes

July 1, 2020

Physician credentialing is the process in which a physician’s credentials are obtained, assessed, and verified. The proper credentialing steps can be complex and time-consuming but are a fundamental responsibility of hospitals and healthcare organizations.

While it is often a tedious administrative task, poor execution can cause serious consequences. Credentialing mistakes lead to financial losses on provider services and credentialing lapses can expose a healthcare organization to malpractice suits and accreditation problems. Even the slightest deviation from credentialing procedures is often enough to make a claim of negligence that will allow a lawsuit to go forward.

8 Common Physician Credentialing Mistakes

  1. Allowing a physician to book cases before credentialing is completed: Courts have ruled that hospitals can be held liable when a physician falsifies their credentials. In one of the earliest negligent credentialing cases, a Wisconsin jury found the hospital 80% responsible for permanent nerve damage suffered by a patient due to a hip surgery gone awry. Although the surgeon falsely claimed in his application that he had privileges at nearby hospitals, the hospital’s urgency to book cases and negligence to verify credentialing held them liable for the majority of damages.
  2. Physician cover-up of prior adverse action: Failing to disclose an adverse action is a serious oversight by any physician, but it is also the responsibility of a healthcare organization to conduct screenings for prior disciplinary actions through a thorough background check. It is critical that hospitals and healthcare organizations verify physicians and verify credentialing through a wide array of databases such as exclusion, sanctions, and debarment lists. It is important to use a trusted source that pulls data from an extensive database. OIG exclusion list monitoring is a keystone of healthcare compliance.
  3. Physicians failing to report adverse actions: Physicians are required to report adverse peer review actions such as license revocation, suspension or voluntary relinquishment of medical staff membership, clinical privileges, or state or federal DEA licenses, and exclusion from third-party programs. Hospital providers will be held accountable for a physician’s omission. Therefore, due diligence requires that real-time checks and monitoring be performed to detect any adverse actions. To protect your organization from fines and exposure, use data-driven platforms to ensure compliance.
  4. Physicians fail to monitor and respond to the National Practitioners Data Bank (NPDB) reports: Reports should be monitored and contested when appropriate; failure to do so may result in significant sanctions. The NPDB requires reporting of the following actions:
  • Medical malpractice payments
  • Federal and state licensure and certification actions
  • Adverse clinical privileges actions
  • Adverse professional society membership actions
  • Negative actions or findings by private accreditation organizations and peer review organizations
  • Healthcare-related criminal convictions and civil judgments
  • Exclusions from participation in a federal or state healthcare program including Medicare and Medicaid exclusions
  • Other adjudicated actions or decisions
  1. Failure to take peer review activity seriously: Institutions that do not stress accountability create cultures in which individuals are less likely to effectively report or share information. This can foster an environment where individuals do not take accountability and instead tend to blame the institution for their actions. Without a collaborative, team-oriented environment of learning, mistakes can become disastrous for healthcare institutions. The initial steps in a peer review or investigation should be taken seriously and should be conducted under due process as outlined by the bylaws. This may correct problems that a physician may not have even known existed.
  2. Whistleblowing in the form of retaliation: Sometimes physicians confuse disruptive behavior with patient advocacy. However, if a complaint is made against a physician or other medical staff, then disclosure of identity should be kept private and dialogue should be conducted via written communications to a quality assurance committee. Communication in regard to the charge and investigation should not be made via undocumented or unprotected communications. However, companies will be held accountable for taking revenge on an employee who has reported an illegal act, an unsafe working condition, financial mismanagement, or any other violation of ethics or law. Employees who suffer retaliation might also be able to recover compensation for retaliation. Examples of whistleblower retaliation include:
  • Termination
  • Demotion
  • Suspension
  • Discrimination
  • Harassment in the workplace
  • Being subjected to a hostile or unsafe working environment
  • Employment penalties or sanctions
  • Denial of benefits, bonuses, or promotions
  1. Neglecting medical staff records: Healthcare providers should not wait to look into credentialing until a peer review action is threatened. Instead, monitoring should occur continually. If a physician or other medical employee passes an initial background check, it does not guarantee their continued competency. Failure to report adverse actions or new exclusions/debarments may come to light with continued monitoring.
  2. Rushing through the credentialing process due to pressure to complete: Although it may be tedious, the credentialing process is critical to safeguard institutions against risk and noncompliance. A thorough review and third-party solution can help hospitals avoid this liability by removing the chance of inconsistency and basic human error. Enlisting an experienced third-party credentials verification organization to supplement and enhance the credentialing process is an optimal solution for streamlining the policy and mitigating risk.

Automating Your Credentialing Process Mitigates Risk

As the legal environment continues to evolve and healthcare organizations experience increased complexity, it is necessary that healthcare providers be proactive in mitigating risk for their organizations. As technology advances, automation makes these processes easier and reduces the number of human errors.

FACIS® is the gold standard in data used for screening, verifying, and monitoring your population of individuals and entities. It is the most comprehensive data set for screening and monitoring health care providers against adverse actions and verifying physician credentials. Information on each provider’s credentials and privileges will be monitored and your organization will be notified if changes occur.

With continual monitoring, your organization can automate and stay compliant for federal program reimbursement, accreditation standards, and state and federal regulatory laws. Thorough and diligent screening will also mitigate the risk of costly negligent credentialing claims against your organization.

Juliette WillardWritten by Juliette Willard
Healthcare Communications Specialist
Being creative is my passion! Writer. Painter. Problem Solver. Optimist.
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