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On the lookout for red flags

Credentialing Resource Center Connection, September 4, 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:

In a previous ezine article, I mentioned that a credentials committee member recently asked me, “How do you know what to look for when analyzing a credentials file?”

In order to fine tune your credentialing and privileging review process your medical staff leaders should first identify red flags with the potential to trigger a more thorough analysis of a particular credentials file. Fortunately, the majority of applicants who apply have what we would call “clean and green” files that are “routine” with no red flags that would raise concerns. So, the idea would be to treat the unusual credentials file in an unusual manner. The following is a list of red flags (your organization may identify others) that warrant a higher level of scrutiny:

• The application is incomplete
• The applicant is found to have experienced an involuntary termination of medical staff membership or involuntary limitation, reduction, denial, or loss of clinical privileges at another organization or has a current challenge or a previously successful challenge to licensure or registration
• Applicant is, or has been, under investigation by a state medical board or has had prior disciplinary actions or legal sanctions
• Applicant has had two or more (or an unusual pattern) of malpractice cases filed within the past five years, or one final adverse judgment in a professional liability action in excess of a particular monetary amount (defined by your organization)
• Applicant has gaps in insurance coverage, change in carriers, or reduction in coverage
• Applicant changed medical schools or residency programs or has gaps in training or practice
• Applicant has changed practice locations more than three times in the past 10 years
• Applicant has practiced or been licensed in three or more states
• Applicant has one or more reference responses that raise concerns or questions (i.e. category ratings are poor, fair, or average, reference letters are neutral)
• Discrepancy is found between information received from the applicant and references or verified information
• Applicant has an adverse National Practitioner Data Bank report
• The request for privileges are not reasonable based upon applicant’s experience, training, and demonstrated current competence, and/or is not in compliance with applicable criteria
• Applicant has been removed from a managed care panel for reasons of professional conduct or quality
• Applicant has resigned as a partner from a group or ended an employment arrangement with a healthcare facility
• Applicant has potentially relevant physical, mental and/or emotional health problems
• Other reasons as determined by a medical staff leader or other representatives of the hospital which raise questions about the qualifications, competency, professionalism, or appropriateness of the applicant for membership or privileges

Once your organization has identified what they consider red flags, then the accompanying tools (application, reference questionnaires) that your organization uses to gather information need to be updated to appropriately capture this type of information, if they weren’t already doing so. In addition, MSPs and medical staff leaders (department chairs, credentials committee, medical executive commitee, etc.) need to be oriented so they know what to look for when analyzing a credentials file.

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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