Provider Re-Credentialing and Privileging:

Provider Re-Credentialing and Privileging:
Do You Really Know Who is Caring for Patients in Your ASC?

Negligent credentialing lawsuits are an avenue — in addition to medical malpractice — through which to pursue legal liability against an ambulatory surgery center (ASC) for the actions of an incompetent or unqualified medical provider, or a previously qualified provider who has made mistakes. ASCs are expected and have a responsibility to conduct reasonable investigations of all licensed independent practitioners (LIPs) that seek privileges, to select only competent LIPs, and to periodically review the performance of the LIPs that are selected.

The purpose of this article is to highlight the importance of LIP reappointment and to briefly discuss some types of information to gather and details of what to verify. It is not intended to be a comprehensive credentialing guide. All ASCs are encouraged to perform a review of the center’s practices to determine if they are consistent with current standards and with the law. Also, the use of the term “provider” — rather than “surgeon” — is intentional because these practices should not be limited to surgeons. Rather, all LIPs such as CRNAs, physician assistants, and nurse practitioners should be granted initial privileges and should be considered for reappointment using the same process.

The following is a partial list of the types of information that is gathered during the reappointment process. It includes suggestions on the level of detail to require, as well as tips on how to assess the information.

• Obtain an updated list of requested privileges. Compare it to previously granted privileges. Require that all requests for additional privileges be accompanied by documentation of training and competence. Be sure that any new procedures are included in the center’s core privileges.
• Verify professional liability insurance coverage and update the status of the LIP’s claim information.
• Obtain a copy of each LIP’s certificate of insurance or policy declaration page. Determine the amount of coverage that is available for an individual claim and the annual aggregate policy limit. Review to ensure that there are no policy exclusions for the types of services provided — individual privileges of the LIP. Also, be sure there are no year-to-year gaps in coverage.
• Review a current claim history to determine not only if there are any new claims, but also the status of previously reported claims. Request that the LIP supply insurance carrier loss runs, information on the amount of awards and settlements, and the specific clinical facts and circumstances of the claims. If there were standard of care issues, also require an explanation for how a similar event will be prevented in the future.
• Obtain a copy of the current license, DEA certificate, status of board certification, and documentation of continuing education. Specifically ask if there is any current action against or challenge to the LIP’s license, DEA number, or certification status.
• Include peer review information in the credentialing process to determine the LIP’s technical proficiency and conduct — both ethical and interpersonal.
• Query other providers and center staff about this individual’s performance and interaction with others.
• Determine if the LIP has been compliant with the center’s medical staff rules and regulations. (For example: Are medical records completed on a timely basis? Does the LIP complete and return patient follow up information, such as infection reports?) 
• Review risk management information such as incident reports, patient complaints, and satisfaction surveys. Determine if there are any adverse trends for this LIP.
• Obtain and include information regarding patient outcomes, such as complications, hospital transfers, admissions, and infections.
• Reconfirm all hospitals and other facilities where the LIP has privileges. Determine if there have been any sanctions or changes to those privileges. Specifically, have any been diminished, suspended, or revoked? Are there any current investigations being conducted or disciplinary actions underway?
• Request information regarding MCO provider panel appointments to ascertain if there have been any changes to the LIP’s appointments or billing practice challenges.
• Be sure that core and individual privileges documents are updated to reflect changes and are readily available for OR booking and clinical staff.
• Implement a procedure for LIPs to receive and sign a code of conduct with the grant of initial privileges and upon reappointment.

Reappointment should not be a routine rollover of clinical privileges. Avoid the cost of defending negligent credentialing or privileging lawsuits and damage to the center’s reputation by adhering to comprehensive reappointment practices.