Friday, April 6, 2018

MedPage Today Investigation Highlights Gaps in Credentialing Process


Instances of incompetent or malicious practitioners have always made headlines, but rarely are the wider systemic issues discussed that allow such events. A recent investigation by MedPage Today and the Milwaukee Journal-Sentinel catalogued at least 500 physicians from 2011-2016 who exploited gaps in the medical licensing system to avoid sanctions or red flags.

In these instances, doctors who had actions taken against them by one state medical board were able to “slip through the bureaucratic net” and operate under clean licenses in other states. Physicians who had formal complaints, suspended licenses, or even permanent revocations maintained their licenses with other state boards, many of whom were not even aware of the action in the first place.

MedPage Today found that the majority of state boards only report their own disciplinary actions against physicians. Their investigation, titled “States of Disgrace: A Flawed System Fails to Inform the Public,” outlines seven categories of information on physician history, including state medical board disciplines, discipline by other states, malpractice claims/payouts, loss of privileges, criminal convictions, Medicare and Medicaid exclusions, and DEA/FDA actions.  Only five states (Florida, Kansas, Massachusetts, Maryland, and North Carolina) regularly reported six of the seven – no state routinely checked and reported all of the above.

The National Practitioner Data Bank, which was created to serve as a central identifying tool for all adverse actions, has not fulfilled its promise of transparency, according to MedPage. A survey conducted by the former NPDB research director found that few state boards made regular queries of NPDB – most states performed only 10 to 20 searches a year, and some didn’t submit any at all. High costs may make NPDB searches prohibitive for some states, but this can result in severe lapses in the information they hold about physicians who are licensed in their states, leading to gaps that can affect patient safety. Out of 64 state medical boards, only 13 subscribed to the “Continuous Query” service which provides alerts for new updates to physician records.

“States of Disgrace” emphasizes the issues that stem from the patchwork system of state licensing boards, but also flags the problem of physicians omitting relevant information in their own applications – whether for licensing or privileging directly at a hospital. NPDB’s survey found that almost 10% of the time, organizations querying the Database found new information about the physician, which shouldn’t occur if the physician was fully forthcoming in their application. “They should never find anything new in an NPDB report,” says Dr. Robert Oshel, formerly of NPDB. This problem is faced in credentialing offices across the nation as well. While it can’t fill in every gap, NAMSS PASS provides a unique ability to understand a practitioner’s full affiliation history, and can protect patient safety by guarding against reticent applicants. Find out more about NAMSS PASS here.

Wednesday, January 24, 2018

Recent Incidents Underscore Importance of Patient Safety

MSPs know that among all their responsibilities, the #1 priority is patient safety. Performing the oftentimes challenging work of credentialing is an essential part of protecting patients and allowing the delivery of high quality health care. Doctors are trusted to care for patients, and it is the job of MSPs to confirm their ability to provide care and that hospitals are aware of any negative incidents that could affect the doctor-patient relationship. Two recent stories underscore just how critical the work of MSPs is.

In Cleveland, USA Today found that a surgeon was accused multiple times of sexually assaulting patients, yet confidential settlements precluded formal charges against him. The Cleveland Clinic, where he was employed, placed him on leave, but did not prevent him from continuing to see patients after a settlement was reached. In fact, when the surgeon later moved to the Ohio State University Medical Center, the facility was unaware of any past allegations regarding the physician. While OSU maintains that the proper credentialing procedure was followed, having official notations of the investigation would have allowed an MSP to determine whether credentials should have been issued in light of the allegations.

Even if the Cleveland Clinic had progressed with formal actions, there was no criminal charge filed. The physician’s record might not have even reflected the settlement, especially if facility itself took on liability, as they often do. If the physician had not disclosed his affiliation with Cleveland Clinic when applying at OSU, or replaced it with another facility where he had privileges, the OSU credentialing department would have had no way of knowing whether he was ever employed at the Clinic, much less whether there had been misconduct.

In an even more recent example, a Maryland-based OB/GYN was found to have falsified his identity, including his Social Security number, to obtain licensure in the state. In fact, over the course of his career, the physician used four different Social Security numbers, three names, and forged dates of birth and education histories to obtain multiple credentials, licenses, and privileges at multiple facilities.

He failed the Foreign Medical Graduate Certification multiple times under different identities before finally passing, and went on to be removed from a residency program in New Jersey for falsifying information and rejected from Medicare for using different Social Security numbers. However, the Maryland facility, Prince George’s Hospital Center, completed the credentialing process for the physician and allowed him to practice medicine for years after the rejection. The intricacies of the fraud demonstrate just how important a thorough and exhaustive credentialing process is.


As all MSPs know, credentialing is an intricate and often winding process. Even the most conscientious MSPs can run into issues of information gaps, whether it is a missing document, an undisclosed affiliation, or any number of other problems that can arise. NAMSS PASS is a free, secure, online database that provides quick and easy access to the affiliation history of practitioners applying for credentials. Through NAMSS PASS, you can automatically review past affiliations for practitioners, disclosed by the hospital, not the physician. This allows you to quickly analyze for any gaps in history, or to identify undisclosed affiliations (a major red flag). In a health care system where patient safety continues to be at risk and must always be a priority, NAMSS PASS can help your facility ensure the highest standard of credentialing is completed. To learn more about NAMSS PASS, please visit http://www.namss.org/NAMSSPASS.aspx

Friday, October 27, 2017

AHA Releases Regulatory Overload Report

The American Hospital Association (AHA) recently released a report entitled Regulatory Overload: Assessing the Regulatory Burden on Health Systems, Hospitals and Post-Acute Care Providers. The report details the extent of regulations promulgated on healthcare providers, spanning four federal agencies.

AHA and Manatt Health found that the four agencies – the Centers for Medicare & Medicaid Services (CMS), the Office of Inspector General (OIG), the Office for Civil Rights (OCR), and the Office of the National Coordinator for Health Information Technology (ONC) – produced 629 separate regulatory requirements across nine domains, in addition to health regulations from agencies outside the four studied. The scope of these regulations and the compliance actions required are significant – health systems, hospitals and PAC providers spend nearly $39 billion combined on compliance per year, and an average-sized hospital dedicates 59 full-time equivalents to compliance.

The AHA report also provided specific recommendations for regulatory relief, including canceling Stage 3 of Meaningful Use, suspending electronic clinical quality measure requirements, and expanding Medicare coverage of telehealth services. MSPs can find the full report here

Wednesday, September 20, 2017

UPDATE: New Guidelines Released as Telemedicine Services Expand

Update: The Joint Commission has retracted the draft standards for telemedicine outlined below, announcing that "At this time, we have closed the field review and decided not to move forward with the proposed telehealth standards." The proposed changes had garnered pushback from some in the industry who were concerned that the standards would be more restrictive than current requirements from the Centers for Medicare & Medicaid Services and state regulators. A spokesperson from TJC told FierceHealthcare that internal review had determined TJC's existing requirements for accreditation adequately applied to telehealth services and that further requirements would be unnecessary. In the future, TJC plans to address enhancements for survey guidance examining telehealth practices and quality and safety issues with telehealth provision.

Telemedicine continues to expand into the healthcare delivery system, and the recent natural disasters across the country have demonstrated just how useful telemedicine can be in a crisis and beyond. As federal and state governments, accrediting organizations, and other healthcare stakeholders recognize the growth and potential of these services, new rules, regulations, and guidelines are beginning to be released. Two major telemedicine efforts were released this month by The Joint Commission and the National Quality Forum.

First, The Joint Commission released proposed revisions to their hospital accreditation standards for hospitals providing “direct-to-patient telehealth services.” TJC, one of the largest and most widely accepted accreditation organizations for hospitals in the United States, introduced changes to two existing standards (Provision of Care Standard 01.01.01 and Rights & Responsibilities of the Individual Standard 01.03.01) and introduced a new standard, Ri.01.08.01. The proposed changes, which are examined in detail here, include requirements for informed consent for patients about the nature of the telehealth services and the provider. The National Law Review article linked above examines how the proposed standards go beyond statutory requirements in some cases, and how they may affect hospitals and other telehealth providers.

The National Quality Forum, an organization contracted by the federal government to develop healthcare performance measures, recently released a report developing a framework for a telehealth quality measurement program. NQF’s Telehealth Committee recommended various methods to measure telemedicine as a care delivery system along four basic categories: access to care, financial impact to patients and providers, patient and clinician experience, and clinical and operations effectiveness. The report, analyzed here by mHealthIntelligence, also highlights specific existing measures that can be applied to telehealth, as well as examining how telehealth activities can fit into the Merit-based Incentive Payment System (MIPS) introduced in the Medicare Access and CHIP Reauthorization Act (MACRA).


NAMSS will continue to monitor developments in telemedicine and their impacts on MSPs. Specifically, NAMSS recently formed a working group in partnership with the American Telemedicine Association to examine the issue of credentialing by proxy for hospitals attempting to credential telemedicine providers at other locations. The group will be developing a packet of educational and instructional materials to introduce MSPs who may not be as familiar with telemedicine to the topic and provide guidelines for developing credentialing by proxy programs at their own facilities. 

Monday, September 11, 2017

CMS Clarifies Guidance on Hospital Definitions

The Centers for Medicare and Medicaid Services recently released a memo clarifying guidance under Appendix A of the State Operations Manual (SOM). This guidance is meant to shed light on the definition of a hospital under the Social Security Act.

With the rise of “microhospitals,” small facilities that operate like acute care hospitals with a low number of inpatient beds, there has been some confusion regarding the certification process for such facilities. A variety of other facility models have run into the same issues, as care providers attempt new innovations in care and locations that may stray from the traditional idea of a hospital facility.

The CMS memo clarifies that the federal Medicare definition of a hospital under the Social Security Act may not always mesh perfectly with state requirements for the same certification. That is, “a facility may have a license from a state to operate as a hospital,” but “that facility may still not meet the Medicare definition of a hospital.” Hospitals approved, certified, and licensed by state or local authorities are still required to fit the Medicare criteria, including Conditions for Coverage (CfCs), Conditions of Participations (CoPs), and observations by the CMS Regional Office in order to be approved to accept Medicare patients. The details of these observations are described in the memo, linked above.

To read more about microhospitals and their growing role in the care delivery system, click here

Thursday, August 17, 2017

Illinois Blockchain Initiative to Pilot Credentials Verification Program

On August 8th, 2017, the Illinois Blockchain Initiative announced a pilot program in partnership with Hashed Health to use blockchain technology to streamline the medical credentialing process in the state. By exploring opportunities through distributed ledger technologies, the program could be able to reduce the complexity of licensing and credentialing. The program will look to provide a new blockchain-based registry to act as a repository for credentialing data.

Eric Fish, senior vice president of legal services at the Federation of State Medical Boards, praised the initiative, remarking that, “If successful, this effort may prompt other state medical boards, as well as others within healthcare, to investigate potential benefits that can be derived from the use of distributed ledgers, and may ultimately result in a more efficient regulatory process without any sacrifice to patient safety.”

To read more on the pilot program, see the full story at Health IT Analytics.

Blockchain technology is a decentralized peer-to-peer system through which digital transactions are created, shared, verified, and stored. This technology consists of three main components: a distributed network, a shared ledger, and digital transactions. The network is the basic skeleton of the blockchain: individual network members generate, verify, and store data on the blockchain, instead of contributing to one central database. The ledger provides a mechanism to share and verify information in the network, protecting the data from tampering and ensuring quick and easy verification of the information within. Finally, a digital transaction is the actual act of generating or verifying data.

NAMSS is continuing to monitor the development of blockchain technology in healthcare, especially with regards to the credentialing process. In May, we hosted our 4th annual Government Relations Industry Roundtable, entitled Building Blocks for the Future. A panel of NAMSS staff, stakeholders and strategic partners discussed the impact of blockchain and its potential applications for the industry. Be on the lookout for further information from NAMSS on blockchain technology and its potential impacts on MSPs!

Friday, July 28, 2017

Obamacare Repeal and Replace Dead, For Now

In the early hours of the morning on July 28, 2017, the Senate held its final vote on Republican efforts to repeal and replace the Affordable Care Act (ACA). The Health Care Freedom Act, referred to by some as “skinny repeal,” fell 51-49, with Republican Senators John McCain (R-AZ), Lisa Murkowski (R-AK), and Susan Collins (R-ME) joining all Democrats in voting against the bill.

The path towards repeal in the Senate had been winding at best. After multiple delays, the Senate narrowly voted to proceed to debate on the House version of the bill, the American Health Care Act (H.R. 1628). Sens. Murkowski and Collins were opposed to the motion, requiring Vice President Mike Pence to provide the tiebreaking vote. The Senate then considered several different options on the repeal efforts, which were all defeated. Senate Republican’s own original plan, the Better Care Reconciliation Act, was soundly defeated, with 9 Republicans from the conservative and moderate wings voting against (57-43).

[Republicans voting against the BCRA were Susan Collins, Lisa Murkowski, Bob Corker (TN), Tom Cotton (AR), Lindsey Graham (SC), Dean Heller (NV), Mike Lee (UT), Jerry Moran (KS), and Rand Paul (KY)]

Next, Senate Majority Leader Mitch McConnell brought up a partial repeal bill, the Obamacare Repeal and Reconciliation Act, which would have repealed essential ACA provisions like the individual mandate, Medicaid expansion, and premium subsidies after a period of two years, during which the Senate hoped to draft a replacement plan. This was voted down 55-45, with Sens. Collins, Murkowski, Heller, McCain, Shelley Moore Capito (R-WV), Rob Portman (R-OH), and Lamar Alexander (R-TN) voting against.

The “skinny repeal” bill was brought up as a last-ditch effort to garner consensus from the Republican caucus on repeal efforts, with the intention of passing a bare-bones bill in order to come up with a fuller plan in conference with the House of Representatives. It would have repealed selected provisions of the ACA, including the individual mandate, delay the employer mandate until 2025, extend the moratorium on the medical device excise tax through December 31, 2020, and modify ACA State Innovation Waivers, among other provisions. For the moment, Republican efforts to repeal the ACA are dead, and Senate leadership has expressed a desire to move onto other business. However, some House Republicans, including Rep. Tom MacArthur (R-NJ), Greg Walden (R-OR) and Freedom Caucus Chairman Mark Meadows (R-NC) have stated they will continue in their efforts to take down the ACA.