How To Verify a Provider’s Application

Apr 26, 2021 | Hugh's Credentialing Digest, Provider Management, Verification

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Charting a Course of Action When Applicant Attestation Conflicts with FACIS® or NPDB Data

When hiring a physician, a fairly common issue is discrepancies on applications regarding legal claims. Standard applications inquire whether the applicant has had “any claims, suits or settlements” and many applicants will say no. However, thanks to medical credentialing data resources such as FACIS® and the National Practitioner Data Bank (NPDB), records of adverse actions, legal claims, suits, and settlements are on file and easily accessed. The availability of this data allows for viable due diligence on a provider applicant prior to submitting the application to the credentials committee. Verified primary source data either validates transparent attestation or exposes attestation with the intent to conceal adverse information. So, how do you proceed when a doctor has legal claims on file?

In this blog post, Hugh Greeley offers a clear course of action for navigating questionable physician applications. He includes clear steps which begin with calling the applicant to confirm all information on the application is correct and tips for how to proceed to ultimately determine whether to continue processing the application or discard it due to false information.

How to Proceed When a Doctor has Legal Claims on File

The following is contributed by Hugh Greeley from his series, “Hugh’s Credentialing Digest”

Recently I received a question from an individual directly involved in the Credentialing Program at her small South Carolina health care facility. Apparently, this facility’s staff have encountered this kind of situation a number of times recently and they wanted to develop a policy or effective procedure to guide their actions in the future.

Here is the scenario she described to me: A physician applies to join the staff and provide services. The individual fills out the application and also submits a copy of their CV. The application is fairly standard and would, I am sure, look similar to the one used at your own facility. In addition to a number of other questions, the application asks if the applicant has had “any claims, suits or settlements against” them or their corporation. In the case at hand, the applicant responded that they had not had any.

Don’t Rely on Attestation Alone. Perform Due Diligence and Chart a Course of Action

Due diligence, including a National Practitioner Data Bank (NPDB) check, subsequently disclosed that the applicant had a number of such settlements in the past.

The question posed to me was this: “What course of action should we take?”

Perhaps the best response would be to pick up the phone and take the following course of action:

Let the applicant know that the application is about to go to the Credentials Committee or director and say that you want to make sure all information is correct. Ask the applicant to confirm what you know about them. For example: “Dr. Smith, this is Jean at such and such facility. I am about to take your application to the committee and would like to make sure I have not missed anything. Could you confirm some information for me? Your application indicates that you went to Chicago Medical School, did your residency at Northwestern, and that you are licensed in three states with no restrictions at all. I have also confirmed your board certification status and your past two hospitals (Lexington and Greenville) both confirmed your time there. You indicated that you have never faced disciplinary action, never lost your license, have not been excluded from Medicare, and that you have NEVER been involved in a claims suit or settlement. Does all of that sound correct?”

Upon hearing this question, the applicant might immediately say, “No, that’s incorrect.
I have been sued three times. I must have made a mistake on my application.” Under these circumstances, you might simply correct the application and give the applicant the benefit of the doubt concerning the omission or error on the application.

On the other hand, if the applicant once again suggests that they have never been sued, etc., then you might say, “That’s interesting, Dr. Smith, the NPDB reported to us that you have had three settlements against you in the past five years. Could you explain this discrepancy to us, please?”

Ethics and Integrity Always

You and your director or credentials chair must then decide if you wish to process the application further or terminate the process due to falsification of the application, which would indicate either a very poor memory (not a good thing for a doctor) or a serious ethical problem (also not a good thing for a doctor, your facility, or your patients).

What Not to Say to an Applying Physician

The worst course of action would be to call the applicant and say, “Dr. Smith, I have been reviewing your application and you said you had never been sued, yet the NPDB data bank lists three suits against you. Should I correct the application for you?”

Solely relying on provider attestation is no longer a necessity thanks to the easy accessibility of digital database resources. When hiring a practitioner, using all resources to verify credentialing and previous legal claims is essential to maintaining the integrity of medical institutions.

Hugh Greeley Written by Hugh Greeley
Credentialing and Healthcare Industry Expert
HG Healthcare Consultant