Walking the new walk
Walking the new walk
How one California facility is coping
Kathryn Biasotti, RN, says Barton Memorial Hospital in South Lake Tahoe, CA, is in the midst of revising its medical staff bylaws and credentialing procedures to take into account the new compliance-credentialing landscape. Biasotti is director of risk and quality management there and also is the compliance officer for the rural facility.
The quality management team last revised Barton’s staff bylaws in 1994. Now, the QI team is going through them paragraph by paragraph with an attorney to make sure everything is consistent with federal laws and regulations as well as with the standards of the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL.
"There are certain things in the bylaws that we need to expand upon," Biasotti says, "including ethical and moral issues that may come up. We’re drilling down in our credentialing process to ensure that it covers all the bases." For example, she says, the team is exploring how to deal with the scenario of the hypothetical physician who applies to Barton’s medical staff who might have been found guilty of abusing federal or state programs at a prior institution.
"First," she says, "we looked at all our physician contracts to make sure they were compliant with the sample compliance plan that Medicare provided to us."
Barton’s medical staff office routinely does a full review with the National Practitioner Data Bank (NPDB). "We now do all our verifications over the Internet — we look into the NPDB as well as checking on physicians’ training and licensure," says Biasotti. "We still re-credential every two years and ask our physicians for updated lists of any pending malpractice settlements or cases. Then we query their insurance companies to verify the information they give us." Once that information is in, the credentialing committee takes over.
Elizabeth Babbitt has been credentialing for five years as the medical staff assistant at Barton. She accesses the Evanston, IL-based American Board of Medical Specialties Web site [www.abms.org; (847) 491-9091] to verify physicians’ board certifications. Babbitt says some boards verify in writing and some over the phone. The board has set up an 800 number for the public to use to verify that their physicians are board-certified. That number gets very busy, so she goes to the Web site instead and queries there.
"At Barton, we do primary source verification," Babbitt says, "so we verify everything from the time physicians get their medical degrees down to the present — fellowships, internships, residencies, employment, all hospitals they’ve worked at. We go directly to the sources for information."
As part of her credentialing job, she ensures the currency of Drug Enforcement Agency (DEA) statuses, licenses, malpractice insurance policies, and required certifications — for example, for neonatal practice. Babbitt directly queries insurance carriers to verify malpractice coverage in writing and asks them to supply a claims history. She also gets new sets of reference letters for the physicians.
Biasotti says that after doing this a few years, you develop a sixth sense — an "intuition" — about whether a physician is misrepresenting the truth. "If we notice a red flag — more settlements than usual, for instance — we take a few more steps than we might take with an application that’s totally clean," she says. Extra steps might include asking the applicant or one of his references for additional endorsements, or having the chief of staff call references in the area of concern. "Sometimes when speaking doctor to doctor, more will be revealed than in writing," explains Babbitt.
She says when she first started, everything she did was monitored, "but by now I know if something isn’t quite right when I read recommendation letters. For example, if a letter says, I wholeheartedly recommend so-and-so,’ you know it’s saying something different from I have nothing derogatory to say.’" The easiest staff members to credential are those fresh out of residency, she adds.
"Of course we query the NPDB," Babbitt says. "If a physician has been sued since his last claims history, he has an opportunity to indicate Yes’ on the application and explain the status of the case. Whatever he says has to match what’s in the NPDB." If a lawsuit is revealed honestly, she says, the case goes to the appropriate committee and makes its way to the medical executive committee.
The file then goes to the board of directors with a recommendation from the medical executive committee — usually a recommendation to approve. "We must be very careful if a file is submitted with a recommendation to deny," says Babbitt, "because some reasons for denial are reportable to the NPDB. Therefore, if a red flag comes up in the credentialing process, we inform the applicant and try to get further information from him. On a very rare occasion, the applicant will choose to withdraw the application instead of offering more information."
Sometimes, Babbitt says, it helps to get input from other credentials workers at hospitals around the country. For that she goes to the National Association of Medical Staff Services Web site [www.namss.org; (630) 271-9814], where there’s a listserv, or an internal e-mail system. "Participants post and receive messages," she says, "and network on what people have done in particular credentialing situations. No names are mentioned, but we discuss cases anonymously."
Listservs like the one run by NAMSS are valuable venues for staffers to ask each other how they do things on a daily basis. For example, a posting may ask what steps another person takes when she sets up competencies under a particular, unusual situation, or how another facility is complying with a certain new regulation.
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