Corporate Compliance

Ensuring confidentiality

Compliance Monitor, March 2, 2007

Q: How can we preserve confidentiality when it comes to our credentialing information?

A: Medical staff services professionals receive many requests for access to credentialing information. State laws vary significantly regarding which parts of credential files are confidential, the individuals allowed access to confidential credentials information, and the conditions under which authorized individuals may obtain access to credentials files.

Hospitals should review all applicable laws and regulations and then develop a specific policy regarding confidentiality of credentials information. Not only will such a policy protect practitioner privacy, it also will provide a solid legal basis for denying access when unauthorized individuals demand to see the files.

Obviously, some information in the credentials file is public, such as any information that can be verified online. However, information that is not public (such as claims history verifications or National Practitioner Data Bank reports) or that cannot be viewed by the applicant (such as peer reference letters) should be kept confidential, and only individuals outlined in the policy should have access to the files.

Therefore, consider separating information that is not universally accessible-for example, peer review information-and placing it in a separate envelope labeled "confidential." This envelope would be part of the file, and if an unauthorized individual seeks access to other information, it will be easy to allow access to only the appropriate information.

Policies also should identify information to which the applicant should have access. For example, applicants should not be allowed to review questionnaires submitted to the organization from peer references or department chiefs. These letters are sent to the references and are completed with the expectation that they will be kept confidential, in order to ensure candid responses in information they provide.

This question first ran in HCPro's Medical Staff Legal Advisor.

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