QUESTION:
While conducting an affiliation verification for a recent applicant, we learned that he is subject to a one year “Conditional Appointment” at another hospital where he has held privileges for 12 years. When this application goes to the Credentials Committee next week, does the failure to disclose the Conditional Appointment constitute grounds to deny the application and, if so, do we have to give the applicant a hearing?
ANSWER FROM HORTYSPRINGER ATTORNEY RACHEL REMALEY:
Should you be interested and/or concerned that an applicant for Medical Staff membership and/or clinical privileges is subject to a “Conditional Appointment” at another hospital? Yes, of course. If another hospital has some sort of question or concern about that individual (which can be the only explanation for a Conditional Appointment), that is something you should know about before you proceed. So, at the very least you will want to place this application on hold and not process it any further until you figure out more details (this means the application should be taken off the agenda for the upcoming Credentials Committee meeting).
With that said…whether or not the failure to disclose, in and of itself, is worthy of any sort of action depends on whether the applicant had a duty to disclose the Conditional Appointment to you. And that depends on what your application forms ask. Do your forms simply ask whether applicants have ever had Medical Staff membership or clinical privileges revoked, restricted, denied, or suspended? If so, the application failed to ask about Conditional Appointments and, in turn, the applicant would have been justified in answering, “No.” If, on the other hand, your application also asks if applicants are currently, or have ever been, under investigation, subject to a formal performance improvement plan, been subject to written conditions, or been subject to a short-term or conditional term of Membership or privileges, then the applicant clearly should have answered, “Yes.”
The questions on the application form should be a reflection of the information that your hospital and its credentialers want to know. This means the questions should be worded to obtain, at minimum, information about all of the threshold eligibility criteria set forth in your Medical Staff Bylaws and/or Credentials Policy. In addition, application forms are often more broadly drafted to ask about additional matters that may fall outside of the threshold eligibility criteria, but still be of interest when considering the applicant’s qualifications. For example, if the threshold criteria simply stated that an applicant may have never been convicted of, or pled guilty or no contest to, a felony, your application form may still ask the applicant about any convictions or pleas for both felonies and misdemeanors.
Once you have determined whether the applicant’s failure to disclose the Conditional Appointment is actionable, the question then turns to whether the appropriate action is for the Credentials Committee to deny the application.
The appropriate response to an omission on an application form depends on your Medical Staff Bylaws, Medical Staff Credentials Policy, and/or related Medical Staff governance documents. We recommend these documents include provisions stating that if a misstatement or omission is identified with respect to any information provided on an application form or during the course of the application process, the applicant will be provided Notice and be given an opportunity to submit an explanation. That explanation will then be considered (often by the Chief of Staff and/or CMO) and a decision will be made about whether to process the application further. The Bylaws/Credentials Policy should clearly state that, in addition, the applicant will then become ineligible to have another application for Medical Staff membership or clinical privileges processed at the hospital (and many organizations go a step further and state that the applicant will also become ineligible to have an application processed at any affiliated entity within the health care system). The Bylaws/Credentials Policy should be clear that refusal to process an application because of the discovery of an omission/misrepresentation is an administrative matter and that does not constitute an adverse professional review action based on a judgment about the applicant’s competence or conduct (and, in turn, does not result in any hearing rights).
If your organization does not have language stating that omissions and misstatements during the application process result in failure to process the application, then any discovery of an applicant’s failure to disclose credentials will have to be managed like other negative information in the credentialing process. This may include determining that the application is incomplete while you follow up with the applicant about the discrepancy and combing through the application with a fine tooth comb to make sure that each and every credential has been independently verified with third party original sources (since you know you cannot count on the applicant to provide complete and accurate information about his or her credentials). Ultimately, if after gathering additional information, you decide to deny the application because you consider the omission to constitute unprofessional conduct, the procedures set forth in the Bylaws for “denials” of applications would apply, including those related to hearings and appeals.
If you have a quick question about this, e-mail us at info@hortyspringer.com.