American College of Physicians: Internal Medicine — Doctors for Adults ®

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Physician credentialing heats up

From for-profits to the AMA, everyone wants to dig into your background-sometimes for a price

From the April 1997 ACP Observer, copyright © 1997 by the American College of Physicians.

By Maureen Glabman

If it seems that your every step-and misstep-is being scrutinized, you may not be paranoid.

Across the country, hundreds of new, aggressive credentialing organizations are busy collecting detailed information on physicians. In addition to conducting routine background checks about physiciansí education, training, malpractice history and licensure, these for-profit companies are looking for details on personal bankruptcy, child support payments and tax records They are packaging the information and selling it to hospitals, managed care organizations, group practices and anyone else who wants to work with-and check up on-physicians.

Illustration by David Chen

At the same time, an even newer type of credentialing organization is springing up that collects detailed information on physicians-but one that physicians themselves pay for themselves. Professional societies like the AMA are taking the lead in creating these organizations, which in effect allow physicians to credential themselves by undergoing a voluntary credentialing process and taking a series of self-assessment exams.

And while it's too early to tell exactly how the race to collect information will affect physicians-experts remain divided on whether competent physicians will be helped or hurt-one thing is clear. As hospitals and HMOs feel pressure from regulatory agencies and health care buyers, collecting-and selling-information about physicians is shaping up to be one of the 1990s' growth industries.

"There is a major push for increasing scrutiny of practitioners," said Martin Merry, MD, an internist in Exeter, N.H. and an expert on physician credentialing. "It's the price we pay for the 1% to 5% of physicians who do not uphold the public trust."

Already, credentialing information is finding its way into the public's hands. In November, Massachusetts became the first state to provide its physician profiles to the public; in January, Florida's Insurance Commissioner announced that anyone with Internet access can obtain physician profile information from the combined files of the Florida Department of Insurance and the Florida Agency for Health Care Administration. Both states also offer consumers information on doctors who have paid malpractice claims, been disciplined by state boards or been stripped of their staff privileges at hospitals and HMOs.

Additionally, Public Citizen Health Research Group has published "13,012 Questionable Doctors,"a three-volume set of books that list doctors found guilty of sexual abuse, substandard care, criminal offenses, prescription violations, drug/alcohol abuse and more. The information is culled from state licensing boards and federal agencies.

A new twist

In one sense, credentialing is nothing new to physicians. For decades, state and county boards of medicine, medical societies and even the AMA have all kept detailed data on physicians. Doctors applying for hospital privileges or any other kind of clinical work have routinely had to undergo background checks and verification of their credentials.

But since the 1970s, credentialing has changed from a relatively easy process in which physicians were presumed innocent until proven guilty to one in which the name of the game is thoroughly checking all aspects of physicians' professional-and sometimes personal-lives. Today, the long list of organizations searching for information on physicians includes not only federal government organizations like the National Practitioner Data Bank and state licensing boards, but malpractice insurers, HMOs and hundreds of commercial credentials verification organizations.

It all began in the late '70s and early '80s, when the Joint Commission on Accreditation of Healthcare Organization (JCAHO) began revising its credentialing rules in response to concerns that hospitals weren't doing a good enough job credentialing their physicians. Then in 1990, the federal government created the National Practitioner Data Bank to keep track of incompetent physicians and bad apples who evaded licensure problems by jumping from state to state.

Perhaps the most significant development, however, has been the recent arrival of for-profit credentialing verification organizations, or CVOs. While only a handful of CVOs existed in 1990, today there are an estimated 250. They have become so commonplace in health care that the National Committee for Quality Accreditation (NCQA), the body that certifies health care plans, recently began surveying CVOs to help HMOs sort the good from the bad.

Hospitals, HMOs and other employers of physicians typically contract with CVOs to credential all their physician employees and sometimes other staff like nurse practitioners. Physicians also can contract directly with CVOs to perform credentials checks on themselves and then direct potential employers looking for credentials information directly to the CVO.

San Diego-based Healthcare Credentials Management Services (HCMS), a large NCQA-credentialed CVO, is typical of the new wave of physician credentialing. Once a hospital or HMO considers working with a physician, the CVO asks that physician for information on 10 items that range from licensure to practice history. The CVO also asks for information on practice history going back five years.

Once HCMS is done collecting information on a physician, it typically gives its report to a credentialing committee working for a hospital, HMO or group practice. That committee then adds its own information-data from member satisfaction surveys, economic performance, complaints, compliance with its program and utilization of resources-and recommends whether the physician be given practicing privileges or hired.

To be fair, CVOs do offer a benefit to physicians: allowing them to fill out a single application and then forward any future requests for credentials directly to that CVO. But that initial application can be a bruiser. Innovative Data Solutions, a Cleveland-based CVO, for example, asks physicians to answer 800 questions.

CVOs ask so many questions because they face fierce competition from other credentialing organizations vying for the same business. Essentially, the most current information wins. "CVOs compete with each other for completeness and accuracy of their files," said Hugh Greeley, a nationally recognized credentialing expert who has written dozens of books and articles on the subject.

The competition comes from a wide range of sources. In addition to the National Practitioner Data Bank, which contains more than 100,000 reports on physicians, the Federation of State Medical Boards also has a database with reports on physicians who have been disciplined by their state medical boards.

Some of the credentialing competition exists at a more local level. Some medical centers, for example, are outsourcing their credentialing work to attorneys. Reid Holbrook, a Kansas City lawyer with Holbrook, Heaven and Faye, frequently conducts extensive background checks for the University of Kansas Medical Center, which has 188 physicians on staff. "We see if they've declared bankruptcy," Mr. Holbrook said. "If the doctor is a poor businessman, that's O.K. But if the bankruptcy is because he had to pay out a malpractice claim and he forgot to mention it, that's something else."

A new kind of credentialing

CVOs now also face a new source of competition: credentialing organizations set up by medical societies like the AMA.

The AMA has launched its American Medical Accreditation Program (AMAP) program to give a "good housekeeping" label to physicians who undergo an examination of their background that includes chart reviews and site visits. Physicians join the program voluntarily-and pay up to hundreds of dollars in fees-to prove to potential employers that they have up-to-date credentials, excellent personal qualifications and patient care results.

When it comes to collecting information on physicians, the AMA has a considerable head start. Most physicians in the country already have some sort of profile with the AMA, even if they have few connections to managed care panels or hospital privileges. The AMA tracks physicians starting with medical school, giving the organization the most comprehensive database on U.S. physicians.

The AMA wants to take this vast supply of physician information and serve as a physician credentialing organization. Just as the JCAHO reviews hospitals and the NCQA puts its stamp of approval on managed care organizations, the AMA wants to lend its stamp of approval to physicians with its new accreditation program.

The AMA plans to take the information it already has in its 90-year-old Master File and supplement it with information on a physician's economic ratings, participation in peer review, self-assessment exams and information from actual site visits. AMAP committees will go a step farther than most credentialing organizations and review a wide mix of patient charts to get a broader view than can be achieved by site visitors from HMOs. While some details were still sketchy at press time, the AMA is trying to position its service as an alternative to the type of credentialing done by HMOs that tends to focus only on physicians' performance only as it relates to individual plans.

A physician's record is flagged if a license has been revoked, suspended, surrendered or has a stipulation of a disciplinary nature. The service lists disciplinary actions but doesn't provide details or background. When organizations like health plans and hospitals want more information on a file, they are referred to the organization that provided the information, such as a state licensing board. No disciplinary information is solicited or collected from residency training programs.

A rollout of AMAP was scheduled for Massachusetts early in 1997, followed by expansion nationwide within five years. ACP is still deciding whether it will participate in the program and forward membership information-MKSAP scores, for example-to AMAP officials.

The AMA isn't the only medical organization jumping into the physician credentialing business. The Federation of State Medical Boards, the umbrella organization in Euless, Texas, for all state licensing boards, also started a physician credentialing organization last August. Physicians can pay up to $200 to have background information such as education, training and licensure certified by the Federation.

A slightly different type of product is being offered by the American Diabetes Association. The Provider Recognition Program allows physicians to prove their worth as diabetologist. Physicians who provide continual care for at least 35 diabetes patients in a 12-month period can pay more than $1,000 to undergo a series of measures that include patient satisfaction to show that they are top-notch caregivers. Unlike the AMA's program and other commercial credentialing organizations, diabetologists do not have to undergo rigid screening of their education, training and legal history.

Defining "good"?

Credentialing experts say that the new programs by professional organizations like the AMA reflect the move toward finding good practitioners and not just weeding out the bad apples. It is part of a growing movement among credentialing organizations of trying to define "good." In the future, "good" physicians may be defined as those who score well on repeated examinations by specialty boards and other organizations, and not just those who have the most prestigious education and training.

It is a concept that specialty boards of medicine are latching onto. Many specialty boards, including the American Board of Internal Medicine (ABIM), have instituted time-limited certificates that require diplomates to prove their proficiency periodically. Internists who became board certified in 1990 have to go through a recertification process by the year 2000, or their board certification status automatically expires.

The idea may be catching on outside of specialty boards as well. Several government agencies are considering the possibility of retesting physicians on their medical proficiency at regular intervals. And while physician organizations agree that additional competency testing is needed, they say that the medical establishment and not the government should establish the examinations.

Eventually, physicians may not only be judged by tests of their clinical competence, but also on tests that measure their humanistic qualities. ABIM, for example, will include some measures of physicians' humanistic characteristics in its recertification process.

While the new breed of physician credentialing service gives physicians a chance to be proactive in getting credentialed-and do a little self-promotion in the process-experts worry that it is only making the competitive environment for work more cutthroat.

There are signs, for example, that some physicians are abusing the credentialing system to gain a competitive advantage. Last November, a New Mexico appeals court awarded a family practitioner $300,000 in damages and ruled that a bad report had been supplied to the National Practitioner Data Bank because the physician was an "economic competitor" of an obstetrician/gynecologist. The ob/gyn had inaugurated peer review actions against the family physician, although there were no problems with family physicianís background or practice patterns.

As physicians are exposed to the flaws of modern-day credentialing, some are fighting back. Most of the cases are related to the National Practitioner Data Bank, which was established in 1990 to keep track of license revocations, restricted hospital privileges, malpractice judgments and other disciplinary actions. Hospitals are required by the JCAHO to query the Data Bank before granting staff privileges to physicians.

Minneapolis health care attorney, Elizabeth Snelson, a renown data bank expert, recently defended a Minnesota physician who received a requisite notice that in 30 days, a permanent unfavorable report on him would be placed in the bank. The problem was the physician had never been the subject of an adverse action but happened to have the same name as another disciplined physician. "We were able to get the record expunged within the 30-day window but it took a lot of legal fees," Ms. Snelson said.

And Reid Holbrook, the Kansas City attorney who represents the University of Kansas Medical Center, recently worked with an internist in his 60s who has been a longtime staff member at the medical center. He admitted four patients or less annually, in a few instances failed to write patient notes and failed to show up for half of medical staff meetings, a requirement of staff physicians.

The internist was not recommended for reappointment to the staff. If after a hearing, the decision not to reappoint is upheld and the hospital trustees agree, information on the doctor must be forwarded to the Data Bank within 30 days where it will be kept permanently. The doctor has hired an attorney to avoid an adverse report on his record that could prevent him from practicing.

Physicians have found other ways to fight censure by the Data Bank. Doctors sometimes avoid database entry by resigning from hospitals before peer review investigations. Hospitals can impose 29-day suspensions, avoiding the requirement to report suspensions of 30 days or more. Or, hospitals may simply push problem doctors out the door without formal charges, avoiding an unpleasant situation while the doctor goes to practice elsewhere with an untarnished record, said Mr. Austin from the Federation of State Medical Boards.

Know your files

The Data Bank may be in a unique situation because it is federally funded, but experts say that it nonetheless raises the point that physicians need to be aware of what information is being collected-and how they can respond.

HCMS, the large CVO, for example, looks for gaps in professional experience. "You don't know if someone took three months off to go to Europe after residency or if it was to spend time in a psychiatric hospital," explained David Buchmueller, president of the CVO.

Company executives advise physicians to be totally truthful on applications submitted to hospitals and managed care organizations. "To be less forthcoming serves them negatively. If we find out about a dismissed suit and nothing was mentioned, you wonder if there is something else the physician is hiding," says HCMS executive vice president, Bernard Minton. "Admitting you were sued and the suit was dismissed gives the appearance of honesty and openness."

If you think that you may have negative information in your file after a CVO checks an application, you should seek personal interviews with the medical director or top management to explain the problem.

Most organizations have some kind of policy to allow physicians to check what their record says about them. Physicians have a once-a-year opportunity to write to the Federation and receive a copy of his file free. If there is an error, it must be corrected through an individual state board.

Maureen Glabman is a Miami-based freelance writer specializing in health care.


Who's collecting information?

Here is a short list of some of the largest organizations collecting-and distributing-physician information. Because many of these organizations share information, inaccurate data in one database can appear in others.

AMERICAN MEDICAL ASSOCIATION
(312-464-5000)
CHICAGO, ILL.

The AMA's American Medical Accreditation Program (AMAP) expands on what's included in its Physician Master File. While all physicians have information in the Master File, only those physicians who participate in AMAP-and pay a fee-will have information in the new program.

What's in your file
Files contain information from medical schools, training programs, medical societies, licensing boards, testing organizations and federal agencies including the Inspector General, the Postal Service, military and law enforcement agencies. AMAP files will also include data on clinical performance and patient care results.

Who can see it
Physicians have access to their own files; health care plans and hospitals need permission from the physician. Patients can find out which physicians have received AMAP certification on the AMA's Web site, but they don't have access to the complete file.

How to correct a file
No procedure is in place yet.

Charges
AMA charges hospitals, HMOs and insurers $12 to receive physician profiles from AMA's Master File; $200-$500 for AMAP files. Physicians seeking AMAP accreditation pay application fees ranging from $50 to $150.

HEALTHCARE CREDENTIALS MANAGEMENT SERVICES INC.
(619-673-7900)
SAN DIEGO, CALIF.

HCMS is only two years old, but it is already one of the largest commercial CVOs. In January, it merged with Equifax Medical Credentials Verifications Services in Atlanta.

What's in your file
HCMS files contain information on education, training, licensure in all states, ECFMG, DEA, Medicare/Medicaid sanctions, board certification, malpractice coverage and claims, National Practitioner Data Bank reports, clinical privileges held, work practice history, physician disclosures regarding malpractice and drug and alcohol abuse.

Who can see it
Health plans, hospitals and anyone else contracting with the credentialing verification organization (CVO) have access to physician files-as long as the physician has agreed to release the information to that organization. Individual physicians can request to see their own files. The public and anyone without physician authorization cannot see physician files.

How to correct a file
Physicians need to send a correction letter on their stationary.

Charges
HCMS charges $15.50 for electronic reports containing information on five data elements: education, license, board certification, DEA status, Medicare/Medicaid sanctions. More detailed paper-based reports cost from $75 to $100. Physicians can request their files at no charge.

THE FEDERATION OF STATE MEDICAL BOARDS
(817-868-4000)
EULESS, TEXAS

The Federation Credentials Verification Services is similar to a credentialing service like the one offered by the AMA; physicians pay a fee to be part of it and must authorize the release of information. The service was started last August, and by January about 170 physicians were subscribing to it.

The Federation also operates an Action Data Bank that contains only reports on physicians who have been disciplined by state medical boards, name changes because of marriage or divorce, duplicate licenses issued. The Action Bank has information dating back to the 1960's and handles 800,000 requests annually.

What's in your file
The Credentials Verification Service contains the identity of physicians by birth certificates or passport, education and post graduate training, license exams taken and actions taken by state licensing boards, including special boards for osteopaths.

Who can see it
Any organization or individual with permission from individual physicians can access files. Physicians may not have a copy of their own file because it can be copied and the CVO would not be able to collect fees.

How to correct a file
To correct information in a file, physicians need to send a letter to the organization.

Charges
Physicians pay $125 to $200 a year or once? to subscribe to the service. There are other surcharges for services like translating documents into English for foreign-trained physicians.

THE NATIONAL PRACTITIONER DATA BANK
(800-767-6732)
CHANTILLY, VA

The Bank is operated by HHS' Health Resources and Services Administration. It contains about 110,000 reports and last year handled 2.9 million queries.

To see if you have a report in the Data Bank, call the telephone number above. A form will be mailed that you fill out and return. Be sure to ask who else has requested information about you.

What's in your file
Files exist on physicians, dentists and other health care professionals who have had adverse actions taken by malpractice carriers, state medical licensure boards, professional societies and hospitals since September 1990. It includes actions that adversely affect clinical privileges for longer than 30 days. Voluntary surrender or restriction of clinical privileges in return for not conducting an investigation is also listed. Physicians who pay malpractice judgments using personal funds do not have a Data Bank file.

Who can see it
Any entity that provides health care services has access. Hospitals are required to query the Bank when considering new staff appointments and to check on their entire medical staff at least once every two years. The Bank is not open to the public.

How to correct a file
Physicians are notified by mail when the Data Bank receives a report. Physicians then have 30 days to propose corrections. Physicians can request that HHS review any report.

Charges
$2 to $7 per name for electronic queries. There is no charge for physicians who want copies of their own files.

AMERICAN BOARD OF MEDICAL SPECIALTIES
(847-491-9091)
EVANSTON, IL

In addition to its electronic database of board certification information, the American Board of Medical Specialties (ABMS) also publishes "The Official ABMS Directory of Board Certified Medical Specialties" in conjunction with "Marquis Who's Who." The book lists information provided by physicians that includes information on training, residency, appointment, place of birth, membership in organizations, as well as ABMS supplied certification data.

What's in your file
ABMS compiles board certification information from 24 different ABMS-recognized boards; information from the 130 medical boards not recognized by the ABMS is not included in the database. The database receives 300,000 queries a year.

Who can see it
Anyone can call the ABMS (800-776-2378) to check if a specific physician is board certified; callers need the physician's full name and zip code. The annual ABMS Directory is available at libraries, and data will soon be available semi-annually on CD-ROM.

How to correct a file
Report to ABMS by letter, telephone or fax for errors in biographical information or board certification status. ABMS will go back to member boards for certification errors.

Charges
The service is free for single queries. The ABMS charges the AMA and other organizations that have an ongoing need for its data.

THE AMERICAN DIABETES ASSOCIATION
(703-549-1500)
ALEXANDRIA, VA

The American Diabetes Association (ADA) has created its Provider Recognition Program to help credential physicians who provide top-notch care for diabetes patients, but it doesn't collect information on education, training and malpractice settlements. The service is voluntary, and physicians pay to take part.

What's in your file
The program will list physicians under two categories of achievement, "Recognition" or "Recognition with Distinction," depending on how well they meet ADA criteria in categories such as how often physicians perform eye and foot exams, how well they educate patients on self-management and patient satisfaction scores..

Who can see it
The ADA plans to publicize the names of physicians recognized by the program. The information will also be made available to health plans and consumers to help them choose physicians.

How to correct a file
Contact the ADA for more information.

Charges
Physicians will be charged $65 for application materials and a $1,200 application fee.

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