In 1965, when the first hospital was found negligent for the actions of its staff, the ruling sent a message to other health care institutions that they will be subject to the same scrutiny as their physicians and other clinicians. Since then, hospitals and physician practices have taken the steps to ensure that all clinicians meet the required criteria for specific medical privileges.
But that process can be complicated, especially when it comes to determining whether something on a medical staff application that looks suspicious is really a red flag. Many medical services professionals (MSPs) struggle to understand what to do. These red flags include:
- Lost privileges
- Frequent moves
- Unexplained work history gaps
- Training program interruptions
- Changes in hospital staff category
- Negative or lack of response from a reference
- Claims or investigations of fraud
- High number of malpractice claims or lawsuits
In the AMA’s February 2023 webinar, “Today's Red Flags: Identifying and Responding to Credentialing Complexities,” Kathy Matzka, CPMSM, CPCS, FMSP, a credentialing, privileging, and medical staff services expert, reviewed several potential medical staff applications red flags and how to address them.
Lost Privileges
When an applicant has lost privileges at another facility, MSPs should determine if those privileges were tied to a contract. For example, a hospital contracting with a radiology group may decide to switch from in-house radiologists to teleradiology. Find out from the applicant and/or the hospital if the loss of medical staff appointment or privileges was due to cessation of an employment agreement or contract.
MSPs should also look for any type of quality, safety, or behavioral issues that may have led to the loss of privileges or the contract cessation. Any disciplinary action or competency issue is a valid reason for concern.
Frequent Moves
Years ago, physicians tended not to move around because the investment required to start and maintain a private practice was significant. In addition, physicians spent considerable time finding office space to rent, hiring staff, and enrolling in health plans.
In today’s healthcare ecosystem, where there is a mix of independent and employed practitioners, the latter are either employed by or contracted with a health system or a large group practice. The office is already set up, and they have staff to handle billing and provider enrollment. So, it’s easier to move from practice to practice, which can appear to be a red flag. When investigating, MSPs should look for involuntary moves where disciplinary action occurred. Oftentimes, this information is difficult to find. If there is no data available from a previous organization about disciplinary action, they should consider asking if the clinician is eligible for rehire.
Work History Gaps
Similar to frequent moves, gaps in work history were once an automatic red flag, but that is no longer the case. It’s not uncommon for clinicians to take advantage of family medical leave when a new baby is born or to care for an ill parent. What is a concern is when employed physicians move from practice to practice with significant time gaps between each position.
Additionally, gaps between training programs are unusual. Typically, physicians will move right into a training program after medical school, and successively work their way through additional programs. Granted, some programs are quite competitive with limited spots, but once a physician is accepted into a program, they should complete it and move into the next one. MSPs should investigate any type of large time gap, especially when it involves a training program that wasn’t completed.
Unresponsive Professional References
Most health care organizations require at least two and, ideally, three references for a medical staff applicant. But, what if those references are not responsive? One common issue is that the applicant provides an address for a referenced physician who rarely practices at that location. As a result, they likely will not see the request letter or it may take much longer to get a response.
MSPs should make sure that applicants provide phone numbers in addition to email addresses to ensure that references can be contacted directly and quickly. If a reference doesn’t reply to an email request within a few weeks, MSPs should contact them by phone. In some cases, they may want to ask for another reference.
Excessive Professional Liability History
Excessive professional liability history thresholds are often specialty dependent. Physicians in high-risk areas with more critically ill patients are more likely to have professional liability actions because it’s the nature of the work. For this reason, MSPs should reference published studies for the specialty or ask the liability insurance provider what its definition of excessive is for a particular specialty.
Additionally, MSPs should distinguish between settlements, judgments, and open and closed claims. A settlement indicates that an agreement was made and either the physician or their insurance company has made a payment. A judgment indicates that a judge or a jury has determined the clinician was negligent and required them to pay money.
Regardless of the red flag, it’s imperative that MSPs document every action taken throughout the process. This will help protect the organization should any issues arise down the road.
Visit AMAcredentialingservices.org for more information on AMA Physician Profiles, AMA Physician Assistant Profiles, and the AMA Profiles Hub.