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Primary verification was the key
"Dr." Dennis Edward Roark managed to practice medicine for more than a decade, never running afoul of the credentialing process at the many institutions where he worked - despite the fact that he was not a doctor. But then he applied for privileges at Ingham Regional Medical Center in Lansing, MI. That's where he found out that a good risk management program can be quite a hurdle for a fake doctor. Roark, a resident of Sterling Heights, MI, pleaded guilty July 15 in Ingham County Circuit Court to a felony charge of using false documents to obtain a medical license. He faces up to 14 years in prison. The 39-year-old Roark also faces possible federal charges for Medicare and Medicaid fraud, related to claims he filed while pretending to be a doctor, plus state charges of insurance fraud.
Roark claimed on state licensing applications and his curriculum vitae that he was a 1986 graduate of Rush University Medical School in Chicago, but the school says he never attended. Prosecutors also say Roark used forged documents, including medical board test scores, to gain admission to four residency programs in Michigan, Ohio, and a Canadian province. Hospitals where he worked report that Roark participated in more than 300 operations, including heart transplants and amputations, though his exact involvement in those procedures remains unclear, prosecutors say.
In addition to the criminal penalties he faces, a disciplinary subcommittee of the Michigan Board of Medicine has fined Roark $100,000 for using phony documents to obtain a medical license. Roark has told the court he has no funds to pay the fine, but failing to pay within 30 days could mean additional prison time. The Detroit Free Press reports that at least two lawsuits have been filed against Roark by former patients, and state officials are investigating cases in which Roark's care may have led to injuries or the death of patients.
His medical license was suspended April 2 when the apparent deception was discovered, but by then, Roark had posed as a heart and lung surgeon for four years and held other physician positions for another 16 years. He had worked in the urgent care center at Madison Heights Commun ity Hospital from 1994 until early 1998. He also participated in a one-year training program at St. Joseph Mercy-Oakland Hospital in Pontiac, MI.
At Madison Heights Community Hospital, chief operating officer Tim Dengel says the facility acted appropriately in credentialing Roark. The state verified that Roark had a valid medical license, he says, and there was no reason to suspect that any of Roark's credentials were invalid.
It is difficult to determine exactly what Roark's experience was, even though it is now known that he posed as a physician for many years and undoubtedly performed many medical procedures and prescribed drugs. While Roark claimed in a summary of cases to the American Board of Thoracic Surgery that he had participated in more than 500 procedures, including eight heart transplants and four lung transplants, prosecutors now say that may have been another lie told to bolster his credentials.
This is a summary of what prosecutors say Roark claimed and what actually happened:
o Graduated from Rush University Medical College in Chicago, 1986 - never attended.
o Conducted post-doctoral research at Washington State University-Veterans Administration Medical Center in Detroit, 1986-1988 - actually never attended.
o Employed as clinical assistant at St. Mary's Hospital in Livonia, MI, 1987-1988 - never worked there.
o Employed as clinical assistant at North - west General Hospital in Detroit, 1988-1990 - never worked there.
o Completed first-year surgical residency at Western Reserve Health System in Youngstown, OH, 1990-1991 - did attend the residency, but it was not renewed.
o Completed second-year surgical residency at St. Joseph Mercy Hospital in Pontiac, MI, 1991-1992 - true.
o Completed third- and fourth-year surgical residency at the Medical College of Ohio in Toledo, 1992-1994 - attended but was fired in May 1994.
It appears that Roark never encountered any serious threats to his charade until he applied for privileges at Ingham Regional Medical Center. He never got as far as practicing there, and risk manager Michelle Hoppes, RN, AHRMQR, says no one at the facility had even heard of him when he submitted his application. There was no immediate cause for concern, she says. Roark was just one more doctor applying for privileges, and so they put his application through the same verification process that all others go through.
Then a few phone calls started setting off the alarm bells and set into motion the process that ultimately would send Roark to prison.
"From a risk management standpoint, this was a very proud day," Hoppes says. "It really shows that risk management is not just the risk manager's job. I'm so proud of our staff and that we were able to stop an individual who could have posed a significant liability risk for our organization and threatened our patients."
A key player in the discovery was Linda Nash, MD, medical director at the hospital. She was in charge of overseeing the credentialing of physicians, and it was her investigation that blew Roark's cover. So how did she do it?
"I can tell you in two words: Primary verification," she says. "You can't take anyone else's word that the credentials are valid. You have to go right to the source and verify it yourself."
The hospital has a strict policy of requiring primary verification for physician credentialing, Hoppes tells Healthcare Risk Management. Obvious ly, not all facilities have the same requirement, relying instead on simply seeing that the applicant has an apparently valid state license and possibly checking his most recent employment. Hoppes and Nash say that is not enough because you are relying on others to verify that the applicant's string of credentials is valid. As Roark demonstrated, even having a "valid" license to practice medicine from the state is not sufficient proof that the applicant has all the training and experience he or she claimed to get the license.
Even if the application is valid with regard to the most important and basic items, such as graduation from a medical school, there may be outright lies or excessive exaggeration about other points that are crucial for whatever type of care the physician intends to provide at your facility.
Hoppes points out that many regulatory bodies require health care providers to verify the credentials of applying physicians, but they usually do not specify exactly what "verification" must entail. Many facilities take a somewhat lax approach, she says, but her hospital always has believed that "verification" means "primary verification" of all significant training and credentials. The risk management department conducts annual audits of the credentialing process, reviewing the files to ensure primary verification.
"We work closely with the credentialing process to make sure that any time there is a red flag, we hold up the whole process and put the burden on the physician to give us what we need," Hoppes says. "Sometimes there is pressure to move things along, but we will not rush the process. A lot of organizations depend on other facilities and the state to have done all the proper credentialing, but it's quite clear to us that we have to depend on ourselves."
Nash says she had never before encountered any serious deceit in the credentialing process, nothing more than some embellishment of a doctor's prior position or involvement. But the hospital's diligence proved worthwhile when she started verifying the information submitted by Roark. The first problem she encountered was that Roark was not listed in the American Medical Association's (AMA) master file of American medical school graduates. Checking that database is the first step in the hospital's verification process.
"But screw-ups can happen, so I didn't think too much of it at first," she says. "Then we sent off a request for verification to the medical school he purportedly went to. When I didn't get an answer right away, I just called them. The registrar said they had looked for his name in every way possible and couldn't find him.
"We had already asked him for a copy of his diploma, so we faxed that over to the registrar's office and he called back right away to say that it was clearly a fake."
Meanwhile, Nash also was trying to contact the references listed by Roark on his application. With one, she kept getting a voice-mail system at the number Roark listed for that reference. After several calls to the voice-mail system, Nash decided to look up the reference's phone number on her own, and she found a completely different number. When she got through to the physician, the director of a residency program Roark supposedly completed, he told Nash that he had no idea what the other phone number was, that he had no voice mail, and that Roark's claim was untrue.
Another reference told Nash that his name was misspelled on Roark's application and that he could not verify the information. While Nash was making these contacts - and after she left messages on the mystery voice mail - Roark called the hospital to say he was withdrawing his application so he could accept another position. But by then, Nash already knew that something was seriously wrong. She called Hoppes in risk management to alert her.
"We consulted with attorneys and looked at the appropriate steps to take," the risk manager says. "We contacted the Michigan licensing board and the attorney general's office. We felt that we definitely were obligated to inform the authorities that he provided falsified information to us."
Hoppes and Nash say the experience confirms what they had believed for years, that primary verification of credentials is worthwhile even when everything appears to be in order. Nash says she would encourage the formation of some sort of centralized database that would eliminate the need for each provider to do primary verification, and she says the AMA's database of medical school graduates is a good first step. All providers should use the AMA database as a starting point for primary verification, she says. As with Roark, failure to find the applicant in the database may be the first sign that you need to look very closely at all of the applicant's credentials.
"Until we get some sort of national system that makes it unnecessary to check for yourself, you can't depend on others to have done the primary verification," Nash says. "This guy apparently set up an elaborate system with phone numbers to call and addresses that were bogus. If anything doesn't seem right, I would encourage you to pick up the phone and see if the reference is from the person it's supposed to be from, and if they can verify what the applicant says."
While a fake doctor poses a challenge to many levels of hospital administration, including peer review and credentialing, Hoppes says risk managers should be actively involved in seeing that the credentialing process is stringent enough to keep charlatans out of the building. Aside from the obvious need to provide competent care to your patients, she says a good system of primary verification will head off major liability risks.
And it is important to remember, she says, that the problem involves more than just the complete fakes like Roark. They may be relatively rare, but Hoppes says the same liability risks can be posed by a physician who substantially overstates his or her credentials. The host organization may be held responsible if it does not realize, for instance, that a surgeon falsely claimed to have advanced laparoscopic training.
"The biggest potential would involve corporate negligence for credentialing," she explains. "You already see that a lot in lawsuits, where the plaintiff says you're responsible just because you credentialed this doctor and then he did something wrong. That's usually a weak argument, but if it turns out that he's not even a doctor, then it would be quite clear-cut that we had some responsibility."
Once a fake doctor is discovered, it is extremely likely that any patient who had a bad outcome with him or her will sue. And when that happens, of course, the hospital's deep pockets are likely to be targeted. The hospital's faulty credentialing process becomes especially attractive to the plaintiff if the fake "doctor" has no money. His or her professional malpractice insurance may not apply, and the doctor may have no personal assets to cover the lawsuits. Roark claimed in court that he was down to his last $1,000 and accepted a court-appointed attorney.
Another area of liability concerns the billing that originates with the fake doctor. Particularly in this time of extreme monitoring by the federal government, it would be a nightmare to realize that your facility had billed for hundreds of thousands of dollars of service provided by a fake doctor or a doctor who grossly overstated his or her credentials.
State Medicaid officials have said that the providers who billed for Roark's services probably will be asked to return the money and may face further investigation. Investigators still are trying to determine whether Roark ever participated in the federal Medicare program. Roark's deception also may lead to changes in Michigan's medical licensing process. Officials are considering random audits of the state's 17,000 licensed health care professionals, plus requiring certified copies of medical school transcripts. Prosecutors say the state licensing board had documents mailed directly from Roark's supposed alma mater, making them believe he had an accomplice working within the medical school.
"On the surface, there was nothing wrong with his application to make you suspicious about it," Nash says. "That's one of the big lessons here. You can't expect the bad applications to look suspicious, so you have to treat them all the same and apply the same procedures to everyone."