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Questions from Credentialing Red Flags webinar with Kathy Matzka

Feb. 8, 2023


Industry expert Kathy Matzka, CPMSM, CPCS, FMSP, presented a webinar entitled Today's Red Flags: Identifying and Responding to Credentialing Complexities on Feb. 1, 2023. Viewers' questions from the live webinar are answered below.

Questions and Answers

Doesn't a provider have to provide proof of CMEs to renew their license?

Not all state medical boards require submission of CME proof for licensure renewal. Many have an attestation statement, the same as many hospitals use on their application/reapplication forms. They are subject to audit by the licensure board. Random audits are performed by the board to ensure compliance with the license requirements.

Should you verify the activity that is listed as a gap?

This may be difficult to verify, especially if the person took time off for personal reasons. The reason for the inactivity should be documented by the applicant. Hopefully, the professional practice questions on the application will identify any areas of concern. Of course, if there is reason to believe that there was something unusual happening during the time off (e.g. inpatient/outpatient rehab), additional research may be necessary.

I've noticed a growing trend with HR offices and Medical Staff Offices that are reluctant to tell you if the person departed in good standing. Not sure what to do in those situations. Any suggestions?

If they won’t provide the needed information, then the applicant should be involved. Most hospital medical staff offices will identify if someone left “in good standing.” If they refuse to provide this information, that may – in itself – be a red flag. Call the medical staff office or personnel office and ask who needs to be contacted and what documentation (e.g., organization-specific authorization for release of information) is necessary to get the needed information. EEOC regulations require that employers maintain personnel or employment records for one year and if an employee is involuntarily terminated, the personnel records must be retained for one year from the date of termination (source). That means that there may not be any record after a year. Individual states may have their own record retention requirements. Many employers will confirm employment dates and job title and/or responsibilities. Some will provide salary history, and information about whether the employer was dismissed or chose to leave on their own. Some will provide information regarding whether or not the employee is eligible for rehire.

Is there any documentation that states a provider must do a U.S. residency when graduating from a foreign school?

This is not addressed in CMS regulations or hospital accreditation standards. Many hospital medical staff bylaws do require completion of ACGME-approved training programs.

Do you bring up at your medical staff meetings any open claims or just when the claim is closed?

The medical staff typically reviews information on open claims at initial and recredentialing. This review can be done by the first level of review (e.g., department chair), or it can be done at a meeting.

How far back does anyone go for claims histories? We are going back ten years, but are looking at changing that.

I’ve seen different policies with different requirements. Many hospitals write to the current professional liability insurer and all past ones on initial appointment. Some go back ten years, some go back five years. NAMSS’ Ideal Credentialing Standards suggest obtaining on initial appointment:

  • Comprehensive list of insurance carriers, including coverage dates and coverage types
  • List of open, pending, settled, closed, and dismissed cases
  • Current certificate of insurance
  • The applicant should provide a listing of all current and past malpractice insurance carriers within at least the past five years, including coverage dates, coverage types, and policy numbers. MSPs should query relevant databases to verify an applicant’s complete malpractice history and ascertain the background, status, and nature of any malpractice cases associated with the applicant. The MSP should verify that the applicant holds current professional liability coverage with limits that meet or exceed their organization’s requirements.

Where can one find out open claims on a practitioner? NPDB?

NPDB does not contain information on open claims. You can write to the insurance carrier and ask for this information. Many court systems have online databases that can be queried.

What is difference between dismissed with prejudice or dismissed without prejudice?

When an action is dismissed by a court, it can be done “with prejudice” or “without prejudice.” Dismissal without prejudice means that the plaintiff can refile the same claim again in that court.

If a practitioner was only named in a lawsuit, but no action taken against them, should the practitioner include that in filling out an appointment/reappointment?

Yes, all claims filed should be reported.

Is it reportable when a provider is late in renewing state licensure?

There is no reporting requirement for a hospital when a provider is late in renewing state licensure. The state may make a report if it takes disciplinary action if it is determined that the practitioner continued to practice without a valid license.

What about a hospital affiliation verification to only give dates? They did not indicate if the provider was in “good standing.”

If the facility did not provide this information, you should make further contact with it to determine the reason it did not or will not provide this information.

Are facilities required to Google new applicants?

No, facilities are not required to “Google” or perform a web search for their applicants. This is just one more tool that can be used to identify potential red flags. Some hospitals do it, and some do not.

Do you use social media or Google when credentialing a provider?

While there are no requirements for such, performing a web search or social media search is one more tool that can be used to identify potential red flags. Some hospitals do it, and some do not. Some organizations ask the vendor that does their criminal background checks to include this option.

Can you point me to some resources for a typical evergreen or evaluation form?

The best option is to modify your facility’s own form that you use to verify appointment at another facility, as these are the questions for which you would like another facility to provide input.

Many locum providers only list on their applications the dates they worked at the facility, and not the official dates of their privileges. How do you handle that in the verification process? It seems it's more important to know when they actually worked there, and not just the privileges appointment approval period.

When it comes to locum tenens, there are different ways of handling prior appointment verifications. Some hospitals verify all, but many only verify some of the affiliations. Recognizing these physicians may be privileged at many healthcare facilities and entities, the hospital may choose to conduct the primary verification procedures for an adequate number of hospitals, health care organizations and/or practice settings with whom the physician is or has previously been affiliated in order to ensure current competency.

Some hospitals may accept primary source verification of credentialing information from the locum tenens entity to supplement its own primary source verification. There needs to be enough information obtained for the medical staff to make a reasoned determination of current clinical competency. In regards to wanting to know the actual dates the practitioner worked at the hospital, the locums agency could probably provide this information.

You suggested using another source in conjunction with NPDB. Which sources are recommended?

When it comes to reports to the NPDB, not all organizations are good about making these, or doing so within the required timeframes. Additional sources for information are the primary sources, e.g., licensure actions with state licensure board, insurance companies for professional liability insurance claims, and hospitals for adverse privileging actions, etc.

Is reporting AP providers to the NPDB as consistent and complete as the MD/DO/DMD/DDS?

No, hospital reporting of actions taken against advanced practice providers to the NPDB is not consistent, as there is no requirement for reporting of these providers.

Perhaps instead of using “average”, use language such as “meets requirements”?

This is up to the hospital. If you are using the language “meets requirements,” the requirements should be defined.

Do peer references really need to have privileges attached?

If you are using the peer reference to determine if the practitioner is competent and qualified for the privileges requested, you do need to provide a copy or a listing of the requested privileges.

If a provider requests to remove privileges, does this need to be reported?

Professional review actions based on reasons related to professional competence or conduct which adversely affect clinical privileges for a period longer than 30 days must be reported to the NPDB. Voluntary surrender or restriction of clinical privileges while under, or to avoid, an investigation must be reported.

HR is not allowed to put anything but we can. :)

Medical staff rules and HR regulations differ. With a signed consent and release form, medical staffs can share peer review information.

When is it considered a red flag if you are asking for other peer references, if the original ones submitted are not responding? Is there a number we should be looking at?

When a peer reference does not provide a reference, this can be a red flag. The reason for not providing the reference should be determined. The number of references required is up to the organization.

Should we have an attestation question that inquires about any training issues?

Some hospitals do include this on application forms. This should be addressed in the verification letter sent to the program director. For an example of such a form, see the Verification of Graduate Medical Education Training (VGMET) form. This forms was developed in collaboration between NAMSS, the American Hospital Association (AHA), the Accreditation Council for Graduate Medical Education (ACGME), and the Organization of Program Director Associations (OPDA) . It captures all primary-sourced components of a practitioner’s medical-education history so MSPs can confirm this information from one source (program directors), one time. Read more from the AHA.

How do you confirm a self-employed provider for over ten years?

I would assume that they would have had to have clinical privileges to work somewhere during this time. Verify the affiliations.

I recently credentialed a physician, but his Internship/residency was not on the AMA Profile, only his medical school. Why would that be? He completed them in 1984.

Always verify any discrepancies with the AMA profile service. It is possible that it was not ACGME-approved training.

Is there an issue that a lot of institutions consider to be a red flag, but you do not consider a red flag today?

Anything that seems to be suspicious is a red flag. A red flag is something that requires some additional review, but the review may, in fact, determine that there is no adverse issue. Physicians that move around a lot or have multiple state licenses used to be looked upon as a potential for a problem. Today, we have an abundance of locum tenens and telemedicine providers whose practice involves multiple licenses and many hospital affiliations.

If you have a nurse practitioner that recently graduated and has never been employed, but did externships that lasted a few months, do we have to verify clinical competency at these places?

Typically, the externship is a part of the training program and the program director should be able to provide this evaluation.

Is Infrequent Observation a red flag?

If what you mean by infrequent observation is a requirement for periodic observation by another provider in order to provide patient care, then yes.

Regarding claims in discovery, are these reportable on applications as open claims?

All claims, including those in discovery, should be reported.


View the recorded webinar


About the author

Kathy Matzka, CPMSM, CPCS, FMSP, is a speaker, consultant, and writer with more than 30 years of experience in credentialing, privileging, and medical staff services. Kathy worked for 13 years as a hospital medical staff coordinator before venturing out as a consultant, writer, and speaker. She is one of the first recipients of the NAMSS Fellow Designation.

Kathy has authored, co-authored, and contributed to almost two dozen books related to medical staff services. She is also a highly regarded industry speaker who has developed and presented more than 500 programs for professional associations and hospitals on topics that include provider credentialing and privileging, medical staff meeting management, peer review, negligent credentialing, provider competency, and accreditation standards.