Washington Association of Medical Staff Services - PowerPoint Presentation

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Washington Association of Medical Staff Services Presented by Eric J. Neiman and Sharon C. Peters

Resolving Disputes in the Credentialing and Privileged World Slide2

Credentialing and Privileging Goal for both is quality and safetyCredentialing verifies whether provider meets certain criteria relating to professional competence and conductPrivileging authorizes access and delineates scopeSlide3

Hospitals and insurers need to know…EducationTrainingLicense(s)DEACDSBoard certificationInsurance coverage

Work history

Medicare/Medicaid sanctions

Malpractice claims

history

Peer references

NPDBSlide4

Conditions of ParticipationCoPs require criteria for determining privileges and for applying criteria regarding individual:CharacterCompetenceTrainingExperienceJudgmentSlide5

Hospital Interpretive Guidelines Sec. 482.22Separate credentials file for eachExamine:Request for clinical privilegesEvidence of licensureTraining and professional educationExperienceSupporting references of competenceSlide6

Accurate information is keyAvoid negligent credentialing claimsEnsure qualityTrack dataStandardized processIn house or delegate to a CVOSlide7

HCQIAHealth Care Quality Improvement Act (1986)Nationwide concern about patient safetyThreat of liability stifled peer review and communicationImmunityLaid groundwork for Data BankSlide8

National Practitioner Data BankCentral repository for information regarding the professional competence or conduct of physiciansHospitals must report; must queryData Bank must be accurate, up to date, and reliable to meet its goalSlide9

National Practitioner Data BankHealth care facilities have obligation to report professional review actions in certain situationsPayors must report medical malpractice payments resulting from written claim or judgmentPeer review or private accreditation organizations must report negative actions/findingNPDB Guidebook issued in April 2015 clarified (some say changed)

the scope of reporting obligations:

http://www.npdb.hrsa.gov/resources/npdbguidebook.pdfSlide10

Adverse clinical privileges actionsDenial, revocation or restrictionAny professional review action that adversely affects clinical privileges for more than 30 days (suspension, conditional proctoring)

Voluntary surrender or resignation while under, or to avoid, investigationSlide11

InvestigationsAcceptance of the surrender of clinical privileges of a physician:(A) While the physician is under investigation by the entity relating to possible incompetence or improper professional conduct,

(B) In return for not conducting such an investigation or proceeding.

42 USC § 11133(a)(1)(A); 45 CFR §60.12Slide12

Voluntarily refrain in lieu of suspension?

Common approach, but consider:

Restriction over 30 days must be reported.

ANY voluntary surrender or restriction must be reported.

If voluntary, during, or to avoid investigation, = report.Slide13

Resolving conflictSlide14

Barriers to resolutionFear of damage to careerFear of NPDB reportMisunderstanding of the processTraditional settlement approach does not applyDefined process can limit creativitySlide15
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Common groundPatient safety Quality healthcareDue processFair decision makingLess paperworkEconomic successSlide17

Resolution can take many formsAlmost always governed by written process...In policies and proceduresOr enrollment applicationOr elsewhere Written process is a private, voluntary contractFollow it exactlyJCAHO requirements and HCQIA requirements differSlide18

Options for resolution?Decisions based on quality and safety are not negotiable.Financial impact should not be considered.Fair hearing processWaiver of fair hearing rightsResignationSlide19

Other optionsLast chance agreementsLimited situationsConsistent with safety and qualityNPDB languageProvider has some say/controlMust be accurate and completeSlide20

Notice to providerRequired by HCQIAInclude details regarding:Proposed adverse decisionDate of decision, and date effectiveSpecific reasons for the decision (include all)

Notice of appeal and hearing rights

Hearing procedure

Ensure the provider receives the notice

Certified mail? Email? Courier?Slide21

Fair Hearing A fair hearing before neutral, objective peersProcedure is as defined in Policies and ProceduresStandard for review is highNot unreasonableNot arbitrary or capriciousFor many providers, there is no other choiceSlide22

Fair Hearing PreparationIdentify and interview witnessesPrepare careful special noticeEnsure that procedure is followed exactlyUse hearing officerSelect hearing panel carefullySlide23

Fair Hearing decision Decision must be written reportSpecial notice requiredFollow appeals process exactlyOnce final, report to NPDB and state medical boardSlide24

NPDB reportsNPDB requires a narrative of the acts or omissions upon which the adverse action was based. Must include sufficient details to provide clear understanding of the allegation, and the nature and reasons for the event upon which the report is based.All in 4,000 characters or less.Required, but risky.Slide25

Disputes Provider may submit a dispute to the data bankWhether the report was eligible for submission, and/orFactual accuracy of the informationOr… provider might also ask the reporter to make a correctionSlide26

Payor Credentialing DisputesAppeal process will be defined in the written proceduresCommon: opportunity to be heard informally, then submit to ADRAlso common: one written appealSlide27

ADR optionsPursuant to clause in the contract:Mediation ArbitrationMediation/arbitrationEarly neutral evaluationSlide28

Benefits of ADRShorter durationLess costDecision maker selection Privacy and confidentialityAvoid hostile litigationSlide29

Washington Association of Medical Staff Services Presented by Eric J. Neiman and Sharon C. Peters

Resolving Disputes in the Credentialing and Privileged World