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January 10, 2023

Beware These Red Flags in Hospital Physician Credentialing

Hospital credentialing of physicians is partly an application and document-gathering procedure, but just as important is the investigative angle. Hospitals must verify information during the physician credentialing process to expose any red flags that were missed during the hiring process. Avoid negligent credentialing lawsuits with a strong primary source verification system and protect patient safety along the way. 

Key Takeaways: 

  • Primary source verification is a key step in the process of physician credentialing 
  • Red flags can be missed during the hiring process, which is why it’s critical for hospitals to employ a thorough and rigorous screening 
  • Neglecting this process, either in part or in full, can lead to negative consequences such as negligent credentialing or medical malpractice lawsuits 

Primary Source Verification in Physician Credentialing 

Perhaps the most important, and therefore most time-consuming, part of the physician credentialing process is the primary source verification stage. During this stage, various details about an applicant are put through a verification process. Information screened during this time may include: 

  • Education 
  • Medical training 
  • Licensure 
  • Experience 
  • Practice 
  • Criminal background check 
  • Exclusions 
  • Debarments 

Red Flags in the Hospital Credentialing Process 

It’s an essential step to identify any red flags that may cause further delays during the application process. While these red flags aren’t necessarily an indication that an applicant is eligible for credentialing, they will still need to be thoroughly vetted. Red flags may include, but aren’t limited to: 

  1. Disciplinary action taken by previous healthcare organizations or licensing bodies
  1. Either voluntary or involuntary relinquishment of licensure
  1. Inconsistent or unexplained gaps in time that aren’t accounted for
  1. Timelines supplied by organizations the applicant was previously affiliated with don’t match the timeline provided by the applicant
  1. Examples of chronic and/or frequent employment changes
  1. Numerous lawsuits
  1. Failure to disclose information
  1. Vague or no reference responses
  1. Interruption of a training program
  1.  Any claims or investigations of fraud

In these cases, more information is needed in order to move forward. Some examples of red flags, like an unexplained gap in time, may have a reasonable explanation. Medical practitioners who have immigrated to the United States may experience a lapse in time between completing their training and beginning their practice due to the relocation or to receive additional required training. 

Costs of Negligent Credentialing 

Hospitals may be liable for negligent credentialing if a patient is injured or caused harm by an unqualified, incompetent or otherwise excluded medical practitioner. A medical malpractice lawsuit may occur, which can cause serious financial and administrative consequences for the medical institution. 

In extreme cases, a negligent credentialing lawsuit could impact an organization’s ability to participate in federally funded programs like Medicare and Medicaid, causing further negative impacts on its revenue stream. This worst-case scenario is preventable through stringent credentialing guidelines and practices.  

Anders Health Care advisors have a partnership with Fifth Avenue Healthcare Services. Together, our advisors provide streamlined credentialing and provider enrollment services. Learn more about our outsourced credentialing and provider enrollment processes or contact an Anders advisor below to get started.

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