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Reviewing claims history at reappointment

Credentialing Resource Center Connection, May 10, 2007

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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:

Spring has finally arrived in my hometown, and the buds are blossoming more and more every day. Recently, I've experienced a budding number of questions regarding the evaluation of claims history at reappointment.

Should the credentials committee or medical executive committee go back and review past claims? And should such a review include claims that are older than the previous 24-month cycle analyzed at the last appointment? Should credentialing staff make information gathered during such reviews available to department chairs at the time of a practitioner's reappointment?  If so, is this fair to the practitioner when the cases have already been discussed and vetted?

Seasoned medical staff professionals (MSPs) and credentialing specialists know that the answers to these questions lie in one's ability to apply the "art of credentialing." In other words, the medical staff needs to evaluate patterns and trends related to claims, settlements, and judgments. True, it may not be appropriate to dwell on older, previously evaluated claims that resulted in a favorable privileging decision. However, when a new claim or malpractice activity surfaces, it may be very appropriate to review the practitioner's previous malpractice history for patterns or trends to see whether the new issue is related in some way.

Assessing malpractice information is an important component of the credentialing process, because it can identify patterns and areas of concern related to a practitioner's clinical practice. Medical staff leaders must have the ability to assess whether a physician's malpractice history is in line with the norm for his or her particular specialty or subspecialty, or whether it needs a more critical eye because it is out of the ordinary.

Some organizations may not request the applicant to provide a detailed claims history at the time of reappointment. They may ask the applicant to attest to any malpractice activity in the last 24 months and query the National Practitioner Data Bank, as required, for information related to settlements.

At a minimum, your reappointment process should obtain from the applicant any information related to his or her malpractice history for the past 24 months, along with a detailed explanation of that history. In addition, your organization should consider establishing a reappointment policy that evaluates the past five years (minimum) to 10 years of history for trends. 

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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