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Does the OIG have a place in your medical staff bylaws?

Credentialing Resource Center Connection, March 20, 2008

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Sally J. Pelletier, CPMSM, CPCS, is a consultant with The Greeley Company, a division of HCPro, Inc., specializing in the areas of credentialing and privileging.

Dear credentialing colleague:

Do your medical staff bylaws address what actions, if any, your organization will take if a medical staff member is sanctioned by the Office of Inspector General (OIG) for Medicare/Medicaid violations? If your medical staff bylaws don't address this, your organized medical staff needs to revise them to make it clear that a practitioner's exclusion from federal healthcare programs is cause for his or her automatic suspension.

The U.S. Department of Health and Human Services' "Special Advisory Bulletin: The Effect of Exclusion from Participation in Federal Health Care Programs," (available here) summarizes the consequences for an organization who violates an OIG exclusion of a sanctioned individual. Those consequences include:

• Civil monetary penalties of $10,000 for each item or service furnished by an excluded individual
• Requirements that the responsible individual pay three times the amount claimed for each item or service

The OIG urges healthcare organizations to screen practitioners using its List of Excluded Individuals/Entities on the OIG Web site (www.hhs.gov/oig). Often healthcare organizations check this list at initial appointment and reappointment. However, it is advisable to routinely check this Web site for all privileged practitioners and to have a process in place for taking actions against a sanctioned practitioner.
 
It is best practice to automatically suspend sanctioned practitioners. This action should not trigger a fair hearing and appeal process. The practitioner should be notified of the reason for the automatic suspension and the appropriate parties notified that the practitioner does not currently hold membership and/or privileges in the institution. This administrative revocation of medical staff membership and/or clinical privileges requires no discussion on behalf of the medical executive committee (MEC) and the governing board for the automatic suspension to occur. However, after the automatic suspension has transpired, the MEC should review and consider the facts to determine if further corrective action is appropriate, including whether termination or denial of medical staff appointment and clinical privileges occur for an applicant or current medical staff member.

Remember, credentialing has no other master than the patient.

That's all for this week.

All the best,

Sally J. Pelletier, CPMSM, CPCS
http://www.greeley.com/consulting.cfm

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