Presentation on theme: "Credentialing, Privileging & the NPDB"— Presentation transcript:
1 Credentialing, Privileging & the NPDB Advising MTFs Re:Credentialing, Privileging, and Reporting to the NPDB3-6 MARCH 2008
2 TerminologyCredentials: documents which constitute evidence of qualifying education, training, licensure, certification, experience, competence, and other qualificationsCredentialing: process of obtaining, assessing and verifying the qualifications of a health care provider
4 TerminologyPrivileging: Process authorizing a specific scope and content of patient care services for a health care practitioner by a health care entity based on credentials and performanceAppointment: Designation by the GB stipulating the provider’s relationship to the medical/dental staff and the degree to which the provider participates in medical/dental staff activities related to governance
5 Illustration by Dave Harbaugh “To give you some idea of today’s bizarre agendahere’s a candidate who wants to be privileged for aprocedure he learned watching Chicago Hope.”5
6 Temporary (not to exceed 30 days) Supervised Types of PrivilegesRegularTemporary (not to exceed 30 days)SupervisedThose who do not hold the required license/certification
7 Medical/Dental Staff Appointment InitialFirst assignment to DoD MTFNot held appointment within previous 180 daysActiveAffiliate: no ECMS responsibilitiesTemporary: Emergency/Disaster situationsNo Appointment
8 Centralized Credentials Quality Assurance System (CCQAS) DoD database for credentials, privileges, adverse actions, risk management, and medical malpractice claimsWeb based, version 2.8 (added privileging processes)Adverse actions module used at the Service level only
9 Reasonable Cause for Adverse Action Single incident of gross negligencePattern of inappropriate prescribingPattern of substandard careAct of incompetence or negligence causing death or serious injuryDocumented substance abuse and refuses or fails rehabPsychiatric disorder not responsive to TxSignificant unprofessional conduct
10 Adverse Actions Due Process TJC requires facilities to have mechanisms, including fair hearing and appeals processes to address adverse decision regarding privilegesDoD R (under revision) will address the minimum requirements
11 Adverse Privileging Action Minimum Due Process Requirements Notification of initiation of an investigation or review of privilegesNotification of the outcome of reviewRight to a hearing, attorney, call and examine witnesses, submit documentsRight to a copy of the record made at the hearingRight to results of the hearing and decision of privileging authorityRight to appeal (final appeal decision TSG)
12 National Practitioner Data Bank (NPDB) Information bank recording medmal paymentsCatalogues disciplinary actions involving licensureInformation bank recording adverse actions against physicians and dentists mandatory, other HCPs optionally.
13 NPDBHealth care entities must report malpractice payments attributed to licensed, certified, or registered providers.Any amount paid, whether whole or in part, lump sum or structured payment if for malpractice on the behalf of a health care practitioner – MANDATORYFailure to report - $10,000 fine
14 HIPDBEstablished 1996 as a fraud and abuse data collection program (part of HIPAA)DoD HA Memorandum 21 Oct 2000TSG Reports (related to health care delivery)UCMJAdverse personnel actions, incl civilianContract termination for default
15 Provider Options When Reported Appeal to TSGDispute with factual accuracy with NPDB/HIPDBAdd an statement to the entry in the NPDB/HIPDBDispute can not serve as an appeal for adverse actionRequest a Secretarial Review by the Secretary of Health and Human Services (must wait 30 days after filing request with reporting entity
16 Discussions with Physician Counsel 10 U.S.C §1102Refer to DoD & Service regulationOk to discuss process for reconsiderationRefer them to for dispute options and general process.
17 CasesCosta v. Leavitt: Fla. District court o/r Sec. HHS & voids Adverse Action report to NPDB.Kadlec Med. Ctr. V. Lakeview Anesthesia Assoc.: Hosp. liable for not reporting adv. Info to other hosp.Poliner v. Texas health Sys.: evidence of actual malice, failure to follow bylaws procedures prior to suspension.
18 Negligent Credentialing Approx. 30 years oldDeveloping c/a in over half the States.Only Kansas has eliminated by statute.Elements:Hosp. granted privilegesProvider was incomp/unqualifiedHosp. knew/ reasonably should have knownProvider negligently treated patientProvider’s negligence caused patient harm.