POLICY AND PROCEDURE
It is the policy of [Facility Name] to require verification of all relevant information provided on applications for Medical Staff appointment and/or clinical privileges.
The American Medical Association’s Physician Masterfile and the American Academy of Physician Assistants Masterfiles contains primary source verification of a number of credentialing elements.
It is the policy of [Facility Name] to use the AMA Physician Masterfile for verification of the following elements for physicians who hold an M.D:
Note: While completion of residency can be verified with the AMA Masterfile, the residency program should also be contacted to verify that the physician has been trained to perform the privileges requested. (See policy and procedure on Verification of Postgraduate Training.)
It is the policy of [Facility Name] to use the AMA Physician Assistant Masterfile for verification of the following elements for physician’s assistants:
Education of physician assistant’s medical school
Certification by the National Commission for the Certification of Physician Assistants
Note: If the Facility contracts with a Credentials Verification Organization (CVO), as the hospital’s agent, the Masterfiles may be requested by the CVO, or the CVO may query directly to the primary source in lieu of using the AMA/AAPA Masterfiles.
Liability History/Proof of Insurance
Malpractice insurance is provided by per occurrence and by an aggregate value. For instance, the policy may provide $1 million per each occurrence with a maximum yearly aggregate amount of $3 million. Most hospitals require proof of liability insurance with a specified minimum face value.
Most hospitals and MCOs require the applicant to provide, at minimum, information concerning current professional liability coverage and any final judgments and settlements. The applicant may be required to provide information regarding current past insurers, whether insurance has ever been canceled by carrier and reasons why, and claims filed and disposition. Often, a letter, such as the one below, is included in the application packet.
It is important for the organization to understand that just because a provider has a malpractice suit, it does not necessarily mean that the provider is incompetent or is a problem provider. The organization must evaluate the liability history of each individual provider to determine whether or not it is significant in relation to the privileges requested. In some physician specialties, for instance orthopedics and neurosurgery, there is a higher rate of malpractice suits filed. In addition, liability insurance providers may settle some lawsuits just because it's cheaper to do so then to go through the litigation. Oftentimes, the provider has no control over these settlements.
[Insurance Company name and address]
RE: [Practitioner name]
Dear Sir or Madam:
I have applied for Medical Staff membership at [hospital name]. As a requirement for this membership, proof of ongoing liability insurance is required. Please add [hospital name] as a certificate holder to my policy and provide a copy of my certificate of coverage to [hospital name] including the limits of the insurance coverage and any additional insured.
Additionally, please provide ongoing notice of cancellation, nonrenewal, or any material limitations in coverage within 30 days in advance for any statutorily permitted reason including nonpayment of premium.
Please also provide [hospital name] with a record of my claims history/loss run including date of the loss, date the claim was reported, name of the claimant, synopsis of what happened, amount paid to date, and whether the claim is closed or open.
Health Status/Ability to Perform
Applicants should be asked to document their ability to safely exercise the privileges requested with or without reasonable accommodation. The Americans with Disabilities Act (ADA) is a federal civil rights law that prohibits discrimination based on disability and bars discrimination against a qualified individual due to the disability. State and local court opinions vary regarding whether ADA applies only to employees only or includes medical staff members. It is up to individual hospitals to determine how the ADA applies to its privileging and credentialing processes. When discussing the issue of the aging provider, it is essential to maintain compliance with state and federal law related to age discrimination. Joint Commission standards require that the hospital evaluate the health status of physicians who exercise, or seek to exercise clinical privileges or other health care services. When the organization employs the physician the ADA applies. If not employed, most hospital medical staffs do not abide by the ADA.
The question that needs to be addressed is whether the physician is currently competent and qualified to safely exercise the privileges granted. Some believe that age is irrelevant. Bylaws and policies should be designed to effectively monitor, review, audit and evaluate how providers perform. This is essential in making a determination as to whether they are meeting expected standards.
Of course, there may come a time when the skills of a provider begin to diminish. If so, steps need to be taken in order to assure that the interests of patient care are seen to while also respecting the rights and privileges of physicians. This may involve a process to review and investigate possible causes. The review should be accomplished in a supportive, collegial manner consistent with bylaws, rules and regulations and applicable policies.
Some medical staffs set a certain age, for instance age 65, at which physicians are required to submit to an annual physical exam.