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Credentialing

Credentialing

Overview

The most common use of the term “credentialing” refers to obtaining and reviewing the documentation of professional providers. Such documentation includes licensure, certifications, insurance, evidence of malpractice insurance, malpractice history, and so forth. Generally credentialing includes both reviewing information provided by the provider and verification that the information is correct and complete. A less frequent use of the term applies to closed panels and medical groups and refers to obtaining hospital privileges and other privileges to practice medicine.

Gillian I. Russell, Terminology, in FUNDAMENTALS OF HEALTH LAW 1, 9 (American Health Lawyers Association 5th ed., 2011).

Policy

One of the most important roles medical staff members play in a healthcare entity is participation in the collection, verification and evaluation of information on applicants for appointment and reappointment to the medical staff. The credentialing process generally occurs in two phases. First, the members of a Credentials Committee (or similar group) must collect, verify (or re-verify in the case of reappointment) and evaluate the pertinent information about an applicant for appointment or reappointment to the medical staff. The initial collection and verification of information may be performed by an administrative person, such as a medical staff secretary, or by a centralized credentialing verification service. Once information has been collected and verified, this first stage requires the Credentials Committee to review an applicant’s application and ensure that all the criteria for appointment have been satisfied. Medical education must be confirmed, membership and certification by specialty boards must be checked, all licensure requirements must be established, confirmation of professional liability insurance must be obtained, and all other pertinent background information must be scrutinized. Once the Credentials Committee has confirmed to the best of its ability that all required criteria for appointment have been met, the Credentials Committee must decide whether the information provided establishes that the applicant possesses the requisite credentials for appointment to the medical staff. When the Credentials Committee decides that an applicant has the necessary credentials to be granted appointment to the medical staff, the Credentials Committee must determine to which category of the medical staff the applicant should be assigned, and what specific clinical privileges should be granted to the applicant.

Because the Credentials Committee makes recommendations to the governing body regarding which applicants should be granted appointment to the medical staff and what clinical privileges such appointee will or will not have at the healthcare entity, there is the potential risk of lawsuits and liability for participation on the Credentials Committee. Nevertheless, HCQIA indicates that such a committee may qualify as a professional review body and thus be eligible for the protection afforded by HCQIA.

Agency Guidance

Once the application is complete, a typical progression is for the Credentials Committee to make a preliminary recommendation regarding the application, and submit the recommendation and the application to the executive committee of the medical staff for comment. This process gives the executive committee some input into the appointment procedure, but keeps the executive committee of the medical staff from controlling the recommendations regarding credentialing. Because the composition of the executive committee typically is controlled by the medical staff rather than the governing body, there is some question whether such a committee would be deemed to be acting "on behalf of" the governing body for purposes of HCQIA immunity. Thus, allowing a Credentials Committee appointed, at least in part, by the governing body, to make credentialing recommendations, helps assure the availability of HCQIA immunity and minimize any exposure the executive committee of the medical staff might face from antitrust or other legal claims arising out of the process.

The final responsibility for approval or disapproval of all applications for medical staff appointment and clinical privileges rests with the governing body of the healthcare entity. The governing body should consider all recommendations of the Credentials Committee, either accepting the recommendation of the Credentials Committee or referring the recommendation back to the Credentials Committee for further consideration. The governing body may propose to take action contrary to a favorable recommendation of the Credentials Committee. If so, the governing body should provide the applicant with written notice of his/her right to a hearing before any final action is taken. If the final action of the governing body is favorable to the applicant’s request, the governing body should provide the applicant with written notification of the acceptance of the application, including the medical staff status and clinical privileges granted. Should the final action be adverse to the applicant’s request, the governing body’s notification to the applicant should state the adverse action taken and include a statement of the reasons for the adverse action. Obviously, any such statement regarding the adverse action should be inclusive of all the reasons supporting the decision, rather than exclusive.

After the Credentials Committee determines that an applicant has the necessary credentials to be appointed to the medical staff, the next step is determining to which category of the medical staff an applicant will be assigned. While some smaller healthcare entities and some specialized healthcare entities do not delineate separate categories of the medical staff, most healthcare entities designate different categories of membership. In those cases where the medical staff is categorized, the distinction may be based on several factors, including the training and professional experience of the applicant, the duration of the applicant’s tenure with the healthcare entity (applicable to an application for reappointment), and the reason such applicant is seeking appointment to the medical staff. The Medicare COP, at 42 C.F.R. § 482.22(c)(2) requires that the medical staff bylaws contain a description of the duties and privileges of each category of medical staff, if such categories are utilized. Although there is no requirement that categories of medical staff be used, when such categorization is implemented, the following categories are used most frequently: Active Medical Staff; Associate or Provisional Medical Staff; Consulting Medical Staff; Courtesy Medical Staff; Honorary Medical Staff; Emergency Department Medical Staff; and Temporary Medical Staff.

Excerpt from Karen S. Rieger, Eric S. Fisher, Stephanie A. Russo, The Fundamentals of Medical Staff Issues: Minimizing Risks and Maximizing Collaboration, Fundamentals of Health Law (American Health Lawyers Association Nov. 2011).