Credentialing & Privileging

Familiarize yourself with the Health Care Quality Improvement Act

Credentialing Resource Center Connection, October 18, 2007

Want to receive articles like this one in your inbox? Subscribe to Credentialing Resource Center Connection!

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:

For MSPs and medical staff leaders, the Health Care Quality Improvement Act (HCQIA), of 1986 is a critical document that we all need to familiarize ourselves with. Please note that this column does not provide all of the details contained within the HCQIA, and I encourage you to read it, or reread it, to remind yourself how it relates to the routine, day-to-day activities of an organized medical staff. You can click here to read the entire Act.

You'll find the history of the HCQIA very interesting, if you aren't already familiar with it: the impetus for the legislation was Patrick vs. Burget. Dr. Patrick, a surgeon, declined partnership in Astoria Clinic in Oregon in order to open his own practice, which was subsequently viewed by the clinic as competition. Then, Dr. Patrick was denied privileges at Astoria's only hospital by the hospital's peer review committee, the majority of whom were partners in the clinic. Dr. Patrick resigned from the medical staff rather than challenge the loss of privileges by completing a hearing on his surgical competence. He also filed a lawsuit alleging that the clinic's physicians violated antitrust laws by using the hospital's peer review system to destroy his practice and therefore eliminate him as a competitor. The jury found that the clinic and its physicians violated antitrust laws and settled out of court ($1,950,000 in antitrust, $110,000 against three individual physicians, $228,600 in attorney's fees). The physicians and the clinic appealed, arguing that hospital activities were based on state law and exempt from federal antitrust law. The U.S. Supreme Court agreed and overturned the ruling, but nonetheless characterized the behavior as "shabby, unprincipled, and unprofessional conduct," (PATRICK v. BURGET ET AL. 486 U.S. 94).

The verdict caused alarm because the constant threat of litigation made physicians  question whether participating in peer review was worth the risk. To alleviate these fears, a bill was introduced by Congressman Ron Wyden of Oregon to provide immunity from antitrust laws for those engaging in "good faith" peer review.

You shouldn't assume that new physician leaders and credentialing specialists know and understand the intent of the HCQIA, and its significance for hospital medical staffs.  Orientation for medical staff leaders and new MSPs should always include a review of the HCQIA and the National Practitioner Data Bank (NPDB) Guidebook. The NPDB was established in 1990 as a central repository/data bank for information relating to professional competence or conduct of physicians and dentists as a result of the enactment of the HCQIA. Its intention, from the beginning, was to serve as a red flag mechanism alongside a strong credentials verification process.

An overview of the Act should include the following:

  • The reasons for enactment
  • Coverage of immunities
  • Standards for professional review action
  • What is not protected/exceptions
  • HCQIA standards - 
         1. NPDB - mandatory reporting obligations
         2. Hearing and appeal procedures

HCQIA provides immunity for peer review actions conducted in good faith if the conditions requisite to the immunity are met., and any actions must be taken in the interest of furthering the quality of care for the patient. As always, check with your hospital's legal counsel for specifics related to compliance with any state or federal law or regulation.

As a side note, it was fantastic to see all the MSPs, vendors, medical staff leaders, industry renowned speakers and presenters, NAMSS support staff, and to network with peers in New York at the annual NAMSS conference. With renewed energy, we all head back to our offices with fresh ideas, a list of "to do" items, and in some cases, maybe we head back with great concern if, during the conference sessions, we learned that our facility is not in compliance with a standard or is not following industry best practices.

Remember, credentialing has no master other than the patient.

That's all for this week.

All the best,

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



Want to receive articles like this one in your inbox? Subscribe to Credentialing Resource Center Connection!

Most Popular

Related Articles