Complaints, Malpractice Coverage/PLI, Medicare/Medicaid Sanctions NAMSS Standards Complaints, Malpractice Coverage/PLI, Medicare/Medicaid Sanctions

Complaints TJC - There must be a process for evaluation of the credibility of a complaint, allegation, or concern against a privileged provider. NCQA - Must continually monitor member complaints for all practitioner sites. There must be a process to monitor and investigate member complaints related to the quality of all practitioner office sites and must conduct site visits for complaints related to physical accessibility, physical appearance and adequacy of waiting- and examining-room space if the organization’s complaint threshold is met.

HFAP - Data collected regarding patient grievances and complaints that are not defined as grievances are reviewed through the QAPI functions. DNV - The hospital must develop and implement a formal grievance procedure, which includes a referral process for quality of care issues to the Utilization Review, Quality Management or Peer Review functions, as appropriate. URAC - There must be a mechanism for conducting additional review and investigation of credentialing applications in cases where the credentialing process reveals factors that may affect the quality of care or services delivered to consumers. Parameters or triggers of potential quality of care issues that require further investigation must be included in a policy.

AAAHC - Risk management process includes an ongoing review of patient complaints and grievances that includes defined response times, as required by law and regulation. Medicare CoP’s - The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.

Malpractice Coverage/PLI TJC - Not addressed. However, if the medical staff bylaws/ rules/regulations require malpractice coverage, it is expected that the organization have a method to verify such coverage. NCQA - The application form must include specific questions regarding the dates and amount of a practitioner’s current malpractice insurance or the organization may obtain a copy of the insurance face sheet from the malpractice carrier. HFAP - Must have evidence of professional liability insurance including current certificates showing amount insurance.

DNV - Medical staff criteria for consideration of automatic suspension includes when the practitioner has failed to maintain the minimum specified amount of professional liability insurance as required in the medical staff bylaws. URAC - Proof of liability insurance included on application. AAAHC - Documentation of professional liability insurance present if required by the organization. Monitored on appointment, reappointment, expiration and on an ongoing basis). Information regarding refusal or cancellation of professional liability coverage provided by the applicant reviewed at initial and reappointment. Medicare CoP’s - Not specifically addressed.

Medicare/Medicaid Sanctions TJC and Medicare CoP’s – Do not address NCQA - Verification of past Medicare/Medicaid sanctions may be done through a query HFAP - The application requests information regarding disciplinary actions taken or investigations pending by Medicare/Medicaid. DNV - Bylaws provide a mechanism for immediate and automatic suspension of privileges due to the termination or revocation of Medicare or Medicaid status. OIG Medicare/Medicaid Exclusions verified at initial, reappointment, and when granting temporary privileges.

URAC - Required to be reported on application URAC - Required to be reported on application. Can verify with issuing organization or NPDB. AAAHC - Information concerning Medicare/Medicaid sanctions disclosed and evaluated on initial and reappointment.