Most Common Provider Credentialing Errors and Real Life Cases to Learn From | symplr

Preventing medical errors that can jeopardize patient safety is a constant challenge within the healthcare industry. Hospital and urgent care center staff, especially, are under incredible pressure to make sure that their providers are competent and capable practitioners, providing the best care possible.

Since the first step in a malpractice case is to prove a physician erred in providing treatment, attention will quickly turn toward determining whether negligent credentialing was a contributing factor.

There’s no question that a carefully executed provider credentialing process is one of the best ways for healthcare organizations to ensure patient safety.

Collecting and Verifying Credentialing Data is Essential

 Credentialing specialists understand the need to collect as much relevant information about an applicant as possible and verify its authenticity. However, even with the latest tools at their disposal and with fast access to data, it’s still surprisingly easy to overlook potential red flags that may have disastrous consequences down the road.

Let’s take a look at some deceptively simple credentialing errors and how to avoid them.

Three Common Mistakes Credentialing Specialists Should Avoid

Despite the most careful and diligent efforts to ensure that a provider meets all necessary criteria, important details can – and do – fall through the cracks. Here are some of the most common reasons why this information is often failed to be considered.

1. Working With Outdated Provider Information

While most of the personal and professional information provided by an applicant during the onboarding process isn’t overly time-sensitive, some are very much so. Specifically, reports about previous disciplinary and/or malpractice claims can sometimes move through the various reporting entities at a slow pace.

Not having the most up-to-date information about the provider’s professional background can mean you might miss critically important warning signs.

Credentialing Warning Signs to Watch

While the National Practitioner Data Bank (NPDB) exists to provide provider background information such as suspensions lasting longer than 30 days, malpractice awards, loss of licensure or privileges, exclusions from health plans, and criminal/civil judgements, it doesn’t always tell the whole story.

For example, a candidate provider may have been the subject of an internal conduct investigation by a previous employer for years, only to have the investigation closed and left unreported upon the provider’s resignation. And even if it had been reported to the relevant medical board or association, the lack of any formal disciplinary action means it may have avoided being captured by the NPDB.

An example of a negligent credentialing claim is the case of Kadlec Medical Center v Lakeview Anesthesia Associates (2006). A patient who had suffered severe brain damage during a surgical procedure launched a malpractice claim and subsequently settled with both Lakeview Anesthetic and Kadlec Medical Center for $7.5 million. Upon reaching the settlement, Kadlec sued Lakeview Anesthesia Associates, claiming that they had provided misleading referral letters concerning the anesthesiologist in question, Dr. Robert Berry.

The suit alleged that both Lakeview Regional and Lakeview Anesthesia had breached their duty to disclose Dr. Berry's history of negligence and narcotics addiction. The crux of the case rested on the fact that Kadlec believed Lakeview knew, or should have known, that the practitioner represented a risk to both entities.

While a jury decided in favor of Kadlec against both plaintiffs, the finding was subsequently appealed to a higher court. The case against Lakeview Regional Medical Center was ultimately overturned for procedural reasons, although, it established unequivocally that hospitals can be open to liability when failing to disclose the activities of former medical staff members.   

For this reason, it’s imperative that credentialing specialists ensure that the background information related to malpractice, conduct, and competence is complete and fully up to date.

2. Missing Primary Source Verification Information

Credentialing teams rely on primary source verification methods to determine the accuracy of supplied provider information. However, some details can be difficult to verify for a variety of reasons, which opens up the possibility of a failure to authenticate critical data.

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 For example, a physician may have graduated from an unaccredited residency or fellowship program but fails to provide contact information for individuals who can corroborate the claim on the credentialing application. Under pressure to complete the credentialing and approve the application, the specialist may turn to non-ideal secondary verification means that lead to delays and which may not always prove as accurate.

It’s critical that the applicant provide the most relevant and accurate contact information necessary to verify their background. Without this critical information, the application should be considered incomplete until it’s provided.

3. Data Entry Errors

Much of the provider data used to drive credentialing and provider enrollment decisions makes its way into a given computer system via data entry. Unfortunately, data entry errors are extremely common, and a simple lack of attention to detail can jeopardize the integrity of the entire provider credentialing process.

To ensure that your provider network data is error-free, credentialing solutions like Cactus along with the nonprofit Council for Affordable Quality Healthcare (CAQH) Proview (formerly Universal Provider Data Source) are highly effective at reducing data entry errors, thanks to the establishment of healthcare provider data collection standards.

Avoid These Common Credentialing Problems

While they may seem simple, these common errors can have unfortunate consequences for both patient safety and organizational liability. And whether you are credentialing a provider applicant or conducting a provider enrollment process to ensure timely reimbursement from insurance companies, adopting best practices and healthcare data management platforms will help ensure positive outcomes.

symplr covers all the angles – from the credentialing, enrollment, and privileging of providers to tracking provider and practice quality to managing vendor and visitor activity in your facility – with advanced solutions, services, and support.

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