Current Issues in Credentialing and Privileging



Hot Topics in Credentialing, Recredentialing, and Privileging Kathy Matzka, CPMSM, CPCSConsultant/Speaker1304 Scott Troy RoadLebanon, IL 62254kathymatzka@website: Phone (618) 624-8124Table of Contents TOC \o "1-2" \h \z \u Liability History/Proof of Insurance PAGEREF _Toc414702889 \h 3Structured Interview Questions PAGEREF _Toc414702890 \h 4Liability History/Proof of InsuranceMalpractice 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. Date][Insurance Company name and address]RE: [Practitioner name][Policy number]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.Sincerely,[practitioner name]Structured Interview QuestionsEducation, Training, Experience, and Current Work Practice and ExperienceBriefly explain your educational background and training.Do you have any specific areas of interest or expertise? If so, explain.Are there any areas of your practice for which you anticipate the hospital would need to purchase additional equipment or would require additional training of staff should the hospital choose to provide these services?Systems-Based Practice1.Please describe the various health care delivery settings and systems in which you will be participating. (i.e. outpatient surgical centers, other hospitals, etc.). 2.Describe how membership on the medical staff of [Hospital name] will develop or build your practice.3.What percentage of your patient practice do you anticipate will be performed at [Hospital name]?4.Describe your anticipated use of consultants.5.Would you be available to provide patient education by participating in educational presentations, development of educational materials, etc?Understanding of Bylaws Requirements(List key issues the medical staff or hospital feel need to be reinforced.)1.Do you understand that the bylaws require you to provide for alternate coverage? Please describe the arrangements you have made for alternate coverage.2.Do you understand that the bylaws require continuous professional liability coverage of at least $1 million per claim and $3 million annual aggregate and if claims made insurance is purchased, you must provide for the purchase of "tail coverage" or "nose coverage"? 3.Do you understand your responsibility for participating in the call rotation for providing care to unassigned patients who present through the emergency department?4.Do you understand the requirements for completion of medical records including automatic suspension provision for incomplete records over ___ days old?Follow-up of Information Received in Application Process (List any issues identified in the application process that require clarification or discussion.)1.Please discuss the details of any malpractice claims that have been filed against you.2.A letter received from one of the hospitals you practiced at it the past documents that you experienced a chronic problem with timely completion of medical records. Please describe the steps you are taking to assure this does not happen at [Hospital name].3.You noted in your application that you are not board certified. Have you applied to take the exam? Have you taken the exam and failed?4.You seem to have changed practice locations a number of times; can you explain the reason for these moves ................
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