What Do We Do With This? Managing Adverse Information

1. What Do We Do With This? Managing Adverse Information CAMSS 41st Annual Education Forum May 18, 2012 Presented by: Patricia E. Brown, BSCJ, CPCS Maggie Palmer, MSA, CPCS, CPMSM

2. Objectives • How the National Practitioner Data Bank (NPDB) Continuous Query Report (CQR) works and how to manage it • Benefits and Risks of Sharing Information • Review guidelines for safely disclosing information

3. NPDB – Continuous Query Benefits ~ Show Me The Money! NPDB-Individual Query Costs • 1000 docs – 100 new apps x 4.75 = $475 500 reappts x 4.75 = $2,375 100 addt’l privs x 4.75 = $475 Annual Total =$3,325

4. NPDB – Continuous Query Benefits ~ Show Me The Money! Continuous Query Costs • 1000 docs x 3.25 = $3,250 • 100 new apps x 3.25 = $325 Annual Total = $3,575 Is the CQR worth the $250 more annually? YOU BET!

5. NPDB – Continuous Query • No more querying NPDB at reappointment • No more querying at time of new privilege requests • Meets JC, DNV, HFAP and NCQA standards

6. NPDB – Continuous Query Finally Someone Works For YOU! • Reports of any actions are sent directly to you. Usually within 24 hours of being reported to the NPDB.

7. NPDB – Continuous Query Challenges • Understanding the process and enrollment decisions • Managing mass reports • Enrollment • Audits • Handling reports as they come in • Disenrolling

9. NPDB – Continuous Query Enrollment • Decide who to enroll • Low Volume only? • Temporary Privileges? • Honorary/Emeritus? • Administrative?

10. NPDB – Continuous Query Enrollment • It’s easy! You can export from your credentialing software. • If you don’t have credentialing software consult the NPDB ~ they have a comprehensive guide book.

11. NPDB – Continuous Query Audit • Mass enrollment lesson learned: • Enroll applicants • Assign your own CQ Practitioner number • Save report electronically for surveyor access • No need to print out each confirmation with mass enrollment • Compare enrollment against medical staff and applicant rosters • Dis-enroll “Off Staff/Termed” applicants who withdraw or denied.

12. NPDB – Continuous Query

13. NPDB – Continuous Query CQR Reports • What if a report is received after credentialing but while applicant is going through review process?

14. Sharing Information

15. Sharing Information Benefits • Credentialing for the community • Reduces duplicative processes (health system) • Possibly reduce incidences of “serial applicants” • Build network with your peers

16. Sharing Information Risks • Improper disclosure • Knee jerk reaction to information before investigating • Loss of credibility

17. Sharing Information Types of ways to obtain/share • Peer to peer • Hearsay • Media reports

18. Sharing Information Peer to Peer Encrypt email Phone call Face to Face

19. Sharing Information Hearsay • SMOKE: ER physician with some past “issues” with complaints of sexual innuendo and is harassing towards nurses. There have not been any formal complaints just hearsay…lots of it. Nurses are reluctant to report a physician. • FIRE: One night ER doc treats a homeless woman for an overdose and spends an usual amount of time with her. A few weeks later the hearsay changes from nurses being harassed to the doctor is using patients as sexual partners in exchange for prescription drugs and/or money. • INFERNO: About six months later the ER doctor is charged with coercing the homeless woman to have sex with his wife while he watched for money (the patient turned him and an no drugs were involved) and now an investigation by the Medical Board and subsequent lawsuit is in progress.

20. Sharing Information Hearsay • Risk Management/Legal Counsel • Document your attempts to obtain formal reports • Google Filter practitioners

21. Sharing Information Media reports • Innocent until proven guilty • Collect articles • Google filter • Tumbleweed • Court documents • MBC action reports

22. Policies & Guidelines • Release language • Absolute Immunity • Release from liability • Indemnify and hold harmless • Attestation questions to consider: • Do you have a release agreement with any organization? • Do you have a behavioral agreement? • Have you ever had a time limited appointment?

23. Policies & Guidelines Court documents are public • Read them! Do they outline compliance requirements or restrictions • Is the application compliant with requirements? • Useful site for querying court documents: Pacer.gov - Public Access to Court Electronic Records (PACER) is an electronic public access service that allows users to obtain case and docket information from federal appellate, district and bankruptcy courts, and the PACER Case Locator via the Internet.

24. Why document? Advantages of good documentation • Creates a record; avoids “institutional memory” issues • Establishes your seriousness • Lays groundwork for legally defensible corrective action if necessary

25. Do not collect to crucify Use care in deciding how collect and when to act • There must be a connection to patient care • DO NOT GOSSIP • Remain professional even if others don’t • Always, always, always seek legal counsel advice and guidance

26. Best practices for responding and disclosing Responding to questionnaires • Respond to all questions • Be truthful, accurate, objective, and base response on clear documentation • If a question asks for an explanation because of a response provided, be brief and to the point • Response, at a minimum, should provide enough information to give the answer proper context. You need not go overboard, but you also want to avoid follow-up questions from the hospital.

27. Best practices for responding and disclosing Have you pulled together all relevant documentation? • Reliance on rumor, innuendo, distant memories, or anecdotal information will only cause problems. • If you don’t know, you don’t know. What form of waiver of liability did the physician sign? • Absolute or qualified? Need to read closely. • No waiver, no response.

28. Best practices for responding and disclosing Questions to ask before responding: • Are there any limitations on what can be disclosed? • State confidentiality/immunity statute • Bylaws/policies which may limit the response • Hospital cut a deal and has a predetermined response

29. Best practices for responding and disclosing Responding to ratings questions: • If you don’t know because of little or low activity levels, simply say so and do not provide rating responses • Try to come up with an agreed-to approach on the profile of a physician who should get highest, middle, and lowest ratings, and strive for consistency • Any rating of average or less will be viewed as evidence of a potential problem physician and may require an explanation • Always make sure you have facts and documentation to support any response

30. Best practices for responding and disclosing Must you disclose response to physician? No, although if requesting an absolute waiver, physician may not sign until you disclose the proposed response If physician refuses to sign an absolute waiver, can you refuse to provide a response? Yes, although you should inform physician that response will not be provided to requesting hospital, which likely will delay processing or result in involuntary withdrawal of application or even denial

31. Special Release Request Re: Dr. Naughty Dear: This letter is in response to the verification request dated xx/xx/xx in relation to Dr. Naughty. Dr. Naughty has been a member of the Medical Staff of Kadlec Medical Center ("Kadlec") since date. In order to supply additional information regarding Dr. Naughty, Kadlec must receive a copy of Kadlec's Authorization and Special Release form signed by Dr. Naughty. To date, Kadlec has not received a signed Authorization and Special Release form with respect to Dr. Naughty and is therefore unable to provide additional information at this time. The release has been forwarded to Dr. Naughty. Please feel free to contact me at 123-456-7890 in the event you should have any questions. If you obtain a signed copy of Kadlec's Authorization and Special Release from Dr. Naughty, please forward to my attention. Thank you.

32. Best practices for responding and disclosing • If questionnaires completed by more than one person (i.e., department chair and division head), attempt to coordinate and strive for consistency, if possible • Make sure that medical staff coordinator or other administrative personnel reviews response before it is sent out

33. Best practices for responding and disclosing • You could also advise physician that if contacted, you will tell hospital that you are withholding response pending signature on absolute waiver • Should I provide a copy of any portion of peer review record? • Never! Never! Never! Once document is released, you should assume that everyone and their uncle will see it, including one or more plaintiff’s attorneys.

34. Best practices for responding and disclosing Am I obligated to respond to subsequent requests for additional information? • If first response was specific enough so as to provide a context or background to questionnaire answers, there is no need or requirement to provide additional information unless otherwise mandated by law • Use your judgment

35. Best practices for responding and disclosing Should I ever provide verbal responses: What if the hospital wants to know the “real story?”

36. What do we do with this now? QUESTIONS? Patricia Brown, BSCJ, CPCS brown.patricia@scrippshealth.org Maggie Palmer, MSA, CPCS, CPMSM palmer.margaret@scrippshealth.org