They pop up in provider background checks, on payer enrollment applications, in practitioner job time frames, and as malpractice claims. They’re red flags. They—and subtler, so-called pink flags—identify data, documents, gaps, discrepancies, or verbal communications that bring into question the validity, accuracy, or existence of an item in a healthcare practitioner’s background. Missing red flags in the primary source verification (PSV) or credentialing process risks patient safety, quality, and reimbursement. At worst, failure to spot and resolve issues may allow an unqualified or undesirable practitioner to be credentialed, privileged, enrolled, employed, or appointed to the medical staff. 

Credentialing professionals conduct "provider quality assurance," poring over large amounts of data they quickly gather, review, and process on physicians, nurses, physician assistants, and advanced practice providers.

Most provider applications don’t raise red flags, but it’s the credentialing professional or medical staff professional’s (MSP) role to delve into questionable items by using technology or just the good old phone. Increasingly, healthcare organizations outsource to, or form their own, NCQA-certified credentialing verification organization. CVOs often have the advantage of focusing solely on PSV and enrollment making them adept at meticulously attending to details.

For new healthcare credentialing professionals and veterans alike, it’s valuable to be reminded of areas where providers may list information that should stop you in your tracks when conducting verifications and credentialing. These five common  items could become apparent when conducting PSV and credentialing.

General areas to watch

  • Incomplete application (any missing documentation)
  • Reluctance by the applicant to give permission to contact previous employers or organizations
  • Resistance by the provider to give info typically gathered during the process
  • Limitation, reduction, or loss of clinical privileges at any previous facility
  • Frequent changes in employment locations or resignations
  • Application is unsigned or undated

Red flags related to insurance

  • Numerous medical liability claims, judgments, or settlements—especially a pattern of unusual or excessive number of professional liability actions resulting in a final judgment against the provider
  • Coverage by multiple and different insurance agencies, periods of no coverage, and/or inadequate coverage amounts
  • Adverse actions by insurers due to quality of care or conduct issues

 Licensing red flags

  • Licensing sanctions
  • Finding that the provider holds a professional license in a state not disclosed on the application
  • Licensing documentation provided by the applicant without supporting material to show they ever practiced or trained in that state
  • Voluntary or involuntary relinquishment of a license

 Professional reference-related flags

  • Incomplete list of references
  • References from all retired practitioners or from non-recent positions
  • Provision of references who give very brief, vague, or indirect responses
  • A lack of response from references
  • Discussion or documentation from co-workers or staff related to professional conduct or possible impairment
  • Information from the applicant doesn't match with data from references or from information gathered by the credentialing professional

Red flags in training and employment history

  • Previous disciplinary actions by a body (healthcare org, licensing body, etc.)
  • History of patient and staff complaints
  • Work time periods unaccounted for or information reported that does not complete a comprehensive timeline, from training through work history
  • Short tenures at multiple organizations
  • Unexplained additional time taken to complete a training program
  • Inability to verify information reported on the application
  • Evidence of poor performance evaluations
  • Training or competency discrepancies relative to requested privilege(s)

Negligent credentialing

Negligent credentialing is defined as the granting of credentials and/or privileges to unqualified healthcare practitioners that can result from a failure to investigate, select, and retain only qualified and competent practitioners. Such lawsuits against healthcare organizations are costly in terms of safety, dollars, regulatory/accreditation status, and reputation. Negligent credentialing goes by many other names:

  • Corporate negligence
  • Negligent selection
  • Negligent supervision
  • Negligent retention
  • Negligent peer review
  • Institutional negligence

Negligent credentialing legal cases brought against hospitals and healthcare organizations typically require that the injured person demonstrate that the healthcare entity failed to fulfill its duty of due care in performing the credentialing process or in granting clinical privileges to the practitioner, and/or the provider acted negligently when providing care. 

DID YOU KNOW: 

  • No official body tracks negligent credentialing lawsuits 
  • There’s no accurate number of cases filed 
  • Most cases are filed in local jurisdictions 
  • Most hospitals settle the cases

About symplrCVO

Ready to take the stress out of credentialing, licensure applications, and payer enrollment? Call on symplrCVO. You’ll get an NCQA-certified team of experts focused on accurate, fast, and scalable services—ready to work with hospitals, health systems, payers, ACOs, IPAs, and beyond. 

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