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Credentialing "red flags"

Medical Staff Legal Advisor, June 18, 2007

Q: Which "red flags" are important to be aware of during the credentialing process?


A: There are different ways to categorize credentialing. "A+" credentialing refers to thorough, detailed verification of all education, training, experience, practice, criminal background, and any other information reported during the credentialing process. "B" credentialing refers to verification of the minimum information needed to meet regulatory requirements. Although this process is sufficient, it is easy to miss detailed information or "red flags" which may not appear without the more thorough verification process.


Red flags include:

  • Time gaps-periods of time that are unaccounted for or information reported by the applicant that does not match the timeline or information reported by the organizations with which the applicant is or was affiliated. Ensure that your credentialing policy defines what will be considered a significant "time gap" (i.e. 30 days or 90 days).
  • Vague or unduly narrow answers from references or references that refuse to complete a detailed evaluation.
  • Numerous lawsuits reported.
  • Prior disciplinary action by any other healthcare organization or licensing body.
  • Failure to disclose information.
  • Extra time needed to complete a training program.
  • Inability to verify information reported on the application.
  • Information indicating that the applicant holds a license in another state that was not listed on the application, and documentation provided by the applicant does not show that he or she ever practiced, trained, or otherwise had a need for a license in that state.
  • Inability to provide references that can attest to current clinical competence.
  • Rumors, discussion, or documentation from co-workers or staff related to professional conduct or possible impairment.
  • Change of insurance companies several times in recent years.


Editor's note: The above information is excerpted from  Medical Staff Law, written by Anne Roberts, CPCS, CPMSM, and published by HCPro, Inc.