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

2. 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

3. 3

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

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

11. 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)

12. 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.

13. 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

14. 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

15. 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

16. Discussions with Physician Counsel
10 U.S.C §1102
Refer to DoD & Service regulation
Ok to discuss process for reconsideration
Refer them to for dispute options and general process.

17. 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.

18. 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.

19. QUESTIONS
QUESTIONS ?