Credentialing, Privileging & the NPDB Advising MTFs Re: Credentialing, Privileging, and Reporting to the NPDB 3-6 MARCH 2008

Terminology Credentials: documents which constitute evidence of qualifying education, training, licensure, certification, experience, competence, and other qualifications Credentialing: process of obtaining, assessing and verifying the qualifications of a health care provider

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Terminology Privileging: Process authorizing a specific scope and content of patient care services for a health care practitioner by a health care entity based on credentials and performance Appointment: Designation by the GB stipulating the provider’s relationship to the medical/dental staff and the degree to which the provider participates in medical/dental staff activities related to governance

Illustration by Dave Harbaugh “To give you some idea of today’s bizarre agenda here’s a candidate who wants to be privileged for a procedure he learned watching Chicago Hope.” 5

Temporary (not to exceed 30 days) Supervised Types of Privileges Regular Temporary (not to exceed 30 days) Supervised Those who do not hold the required license/certification

Medical/Dental Staff Appointment Initial First assignment to DoD MTF Not held appointment within previous 180 days Active Affiliate: no ECMS responsibilities Temporary: Emergency/Disaster situations No Appointment

Centralized Credentials Quality Assurance System (CCQAS) DoD database for credentials, privileges, adverse actions, risk management, and medical malpractice claims Web based, version 2.8 (added privileging processes) Adverse actions module used at the Service level only

Reasonable Cause for Adverse Action Single incident of gross negligence Pattern of inappropriate prescribing Pattern of substandard care Act of incompetence or negligence causing death or serious injury Documented substance abuse and refuses or fails rehab Psychiatric disorder not responsive to Tx Significant unprofessional conduct

Adverse Actions Due Process TJC requires facilities to have mechanisms, including fair hearing and appeals processes to address adverse decision regarding privileges DoD 6025.13-R (under revision) will address the minimum requirements

Adverse Privileging Action Minimum Due Process Requirements Notification of initiation of an investigation or review of privileges Notification of the outcome of review Right to a hearing, attorney, call and examine witnesses, submit documents Right to a copy of the record made at the hearing Right to results of the hearing and decision of privileging authority Right to appeal (final appeal decision TSG)

National Practitioner Data Bank (NPDB) Information bank recording medmal payments Catalogues disciplinary actions involving licensure Information bank recording adverse actions against physicians and dentists mandatory, other HCPs optionally.

NPDB Health care entities must report malpractice payments attributed to licensed, certified, or registered providers. Any amount paid, whether whole or in part, lump sum or structured payment if for malpractice on the behalf of a health care practitioner – MANDATORY Failure to report - $10,000 fine

HIPDB Established 1996 as a fraud and abuse data collection program (part of HIPAA) DoD HA Memorandum 21 Oct 2000 TSG Reports (related to health care delivery) UCMJ Adverse personnel actions, incl civilian Contract termination for default

Provider Options When Reported Appeal to TSG Dispute with factual accuracy with NPDB/HIPDB Add an statement to the entry in the NPDB/HIPDB Dispute can not serve as an appeal for adverse action Request a Secretarial Review by the Secretary of Health and Human Services (must wait 30 days after filing request with reporting entity

Discussions with Physician Counsel 10 U.S.C §1102 Refer to DoD 6025.13 & Service regulation Ok to discuss process for reconsideration Refer them to www.npdb-hipd.com for dispute options and general process.

Cases Costa v. Leavitt: Fla. District court o/r Sec. HHS & voids Adverse Action report to NPDB. Kadlec Med. Ctr. V. Lakeview Anesthesia Assoc.: Hosp. liable for not reporting adv. Info to other hosp. Poliner v. Texas health Sys.: evidence of actual malice, failure to follow bylaws procedures prior to suspension.

Negligent Credentialing Approx. 30 years old Developing c/a in over half the States. Only Kansas has eliminated by statute. Elements: Hosp. granted privileges Provider was incomp/unqualified Hosp. knew/ reasonably should have known Provider negligently treated patient Provider’s negligence caused patient harm.

QUESTIONS QUESTIONS ?