Credentialing, Privileging & the NPDB

1. Credentialing, Privileging & the NPDB Advising MTFs Re: Credentialing, Privileging, and Reporting to the NPDB 3-6 MARCH 2008

2. Terminology • Credentials: documents which constitute evidence of qualifying education, training, licensure, certification, experience, competence, and other qualifications • Credentialing: process of obtaining, assessing and verifying the qualifications of a health care provider

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4. Terminology • Privileging: 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 performance • Appointment: 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 agenda here’s a candidate who wants to be privileged for a procedure he learned watching Chicago Hope.” 5

6. Types of Privileges • Regular • Temporary (not to exceed 30 days) • Supervised • Those who do not hold the required license/certification

7. Medical/Dental Staff Appointment • Initial • First assignment to DoD MTF • Not held appointment within previous 180 days • Active • Affiliate: no ECMS responsibilities • Temporary: Emergency/Disaster situations • No Appointment

8. Centralized Credentials Quality Assurance System (CCQAS) • DoD database for credentials, privileges, adverse actions, risk management, and medical malpractice claims • Web 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 negligence • Pattern of inappropriate prescribing • Pattern of substandard care • Act of incompetence or negligence causing death or serious injury • Documented substance abuse and refuses or fails rehab • Psychiatric disorder not responsive to Tx • Significant unprofessional conduct

10. Adverse ActionsDue Process • TJC requires facilities to have mechanisms, including fair hearing and appeals processes to address adverse decision regarding privileges • DoD 6025.13-R (under revision) will address the minimum requirements

11. Adverse Privileging ActionMinimum Due Process Requirements • Notification of initiation of an investigation or review of privileges • Notification of the outcome of review • Right to a hearing, attorney, call and examine witnesses, submit documents • Right to a copy of the record made at the hearing • Right to results of the hearing and decision of privileging authority • Right to appeal (final appeal decision TSG)

12. National Practitioner Data Bank (NPDB) • Information bank recording medmal payments • Catalogues disciplinary actions involving licensure • Information bank recording adverse actions against physicians and dentists mandatory, other HCPs optionally.

13. NPDB • Health 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 – MANDATORY • Failure to report - $10,000 fine

14. HIPDB • Established 1996 as a fraud and abuse data collection program (part of HIPAA) • DoD HA Memorandum 21 Oct 2000 • TSG Reports (related to health care delivery) • UCMJ • Adverse personnel actions, incl civilian • Contract termination for default

15. Provider Options When Reported • Appeal to TSG • Dispute with factual accuracy with NPDB/HIPDB • Add an statement to the entry in the NPDB/HIPDB • Dispute can not serve as an appeal for adverse action • Request 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 §1102 • Refer to DoD 6025.13 & Service regulation • Ok to discuss process for reconsideration • Refer them to www.npdb-hipd.com for dispute options and general process.

17. Cases Costa 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 old Developing c/a in over half the States. Only Kansas has eliminated by statute. Elements: • Hosp. granted privileges • Provider was incomp/unqualified • Hosp. knew/ reasonably should have known • Provider negligently treated patient • Provider’s negligence caused patient harm.

19. QUESTIONS QUESTIONS ?