credentialing

May 7, 2026

Posted on by Courtney Patterson

QUESTION:
Over the course of the past six months, three different physicians were recruited by our affiliated medical group who had significant issues – none of which were identified until they had applied for appointment and privileges at our hospitals.  And I mean big issues – one of the physicians didn’t even meet our threshold eligibility criteria because of a past licensure action!  We keep being told “they’ve been vetted already!” with lots of pressure to “get it done” when it comes to their credentialing.  We don’t know what they’re looking at in their “vetting” process, but it sure doesn’t seem to be what we’re looking at in credentialing.  Beyond the obvious waste of resources this is causing (both time and money!), it’s also starting to create serious strain between those of us involved in credentialing and the administrative team.  Is there a fix for this?

ANSWER FROM HORTYSPRINGER ATTORNEY LEEANNE MITCHELL:
First, if it helps you feel better, virtually every health system in the country is struggling with how to better align recruitment/employment and credentialing to avoid the very issues that your hospital is dealing with.  A big part of this problem is that for a very long time, the employment of physicians just didn’t exist, so now, we are trying to figure out how to best make these very different processes work together.

The other thing to understand is that when the individuals involved in recruitment say that these candidates have been “vetted” – they very likely have; however, the extent of information that is obtained in the standard employment process is very different than the extent (and type) of information we get in medical staff credentialing.  For example, while employers do verify past employment affiliations, an incredibly forthcoming employment reference will provide dates of employment and whether the individual is eligible for rehire.  That’s it.  And the vast majority only provide dates.  Recruiters tend to be astounded when they find out how much information we get in credentialing.  Unfortunately, that process – which is going to provide you with the much more detailed information – virtually always happens second (sometimes after contracts have been signed and money has changed hands).

So, is there a fix?  The perfect solution would be to not make any employment overtures until an identified candidate has been fully credentialed, which we also understand is impractical, and, frankly, just isn’t going to happen.  Short of that, given that it’s the employment screening or vetting that is occurring first, it’s vital to get everyone on the same page in terms of the qualifications that a physician must meet to be on your medical staff AND the types of “red flag” issues that might be identified in a candidate’s background that will, at the very least, slow down the credentialing process because they will require further review and which might end up being significant enough that the individual doesn’t make it through credentialing – whether that’s in the form of an application that remains incomplete because we can’t get sufficient information to resolve the concerns or through a denial.

We recommend that health systems sit down with their recruiters (whether internal or external) and explain exactly how the credentialing process works, what kind of information is requested, what primary source verification means and requires, what the hospital’s bylaws require, and what is typical in a healthcare provider’s background (and what isn’t).  Then, to go a step further and create recruitment screening tools for their recruiters to use very early on in the process of identifying candidates.  This tool should begin with the threshold eligibility criteria in the medical staff bylaws – with the recruiters understanding clearly that not meeting threshold criteria is a hard stop as no one can be guaranteed to get a waiver of such criteria.  Beyond threshold eligibility criteria, the screening tool should also identify significant red flags that are going to slow down the process – if for no other reason than for the employment side to be envisioning logical start dates (i.e., don’t think this candidate will be on the call schedule next week!).  So, for example, on the threshold eligibility criteria list may be that a candidate can’t have had a past licensure suspension in any state, while the red flag list includes having had terms of probation or conditions placed on a license in the past.

While not a perfect solution, ensuring that the recruiters understand the credentialing process itself and then the routine and consistent use of a more detailed screening tool can definitely help with these issues.

If you have a quick question about this, e-mail LeeAnne at info@hortyspringer.com.

July 10, 2025

Posted on by Courtney Patterson

QUESTION:
We are having a hard time getting medical staff members who are willing to serve on committees and currently have a significant number of medical staff spots that we need to fill on our infection prevention committee, performance improvement committee, tissue committee, and the pharmacy and therapeutics committee.  One idea was to try and consolidate some of these functions so there are fewer committees.  Is this doable? Advisable?

ANSWER FROM HORTYSPRINGER ATTORNEY LEEANNE MITCHELL:
In terms of the fast answers – (1) likely yes, and if so, (2) absolutely yes!  One of the biggest concerns that we hear being raised these days is that the medical staff leadership pool – whether that means individuals willing to serve as medical staff officers, department chairs, committee chairs, and even committee members – is shrinking dramatically.  Sometimes it’s difficult to populate even the committees that fulfill the primary “medical staff functions” like credentialing, privileging and peer review, often leaving very slim pickings for the ancillary hospital committees.

In terms of whether it’s “doable,” one thing to verify first is what your state hospital licensing regulations may require in terms of medical staff or hospital-specific committees.  While most state regulations just speak in terms of specific functions that have to be fulfilled – often by a committee – some (here’s looking at you Pennsylvania!) do specify a number of separately named committees that hospitals are expected to maintain.

However, in the absence of any regulatory constraints, the manner in which you decide to assign the various functions that have to be met within the hospital to different committees is purely discretionary.  It has become common to see a single overarching “quality committee” that fulfills the functions that used to be performed by separate infection control, P&T, tissue/transfusion, performance improvement, and quality committees.  The key is that you want to ensure that the necessary functions are being fulfilled and that your committees – whether one, two or ten – are organized in such a way as to ensure that occurs.

If you have a quick question about this, e-mail LeeAnne at LMitchell@hortyspringer.com.

February 6, 2025

Posted on by Courtney Patterson

QUESTION:
There is a private subreddit discussion group in which only Medical Staff professionals are approved to participate.  Most members of the group seek advice on credentialing, privileging, and peer review issues.  Community guidelines within the group caution against identifying the practitioners involved in their questions.  However, some posts may include specific details about problematic credentialing files or behavior incidents.  In some instances, individuals who post questions may include information such as their name and the hospital at which they work.  A few of our leaders are wondering if joining this group would help to bounce ideas off other Medical Staffs and their leaders.  Is this problematic?

ANSWER FROM HORTYSPRINGER ATTORNEY MARY PATERNI:
While we don’t mean to discourage professional interactions among Medical Staff professionals, there are legal risks to discussing credentialing and peer review issues about individual practitioners on social media.

Let’s be real, it’s social media.  There is never any guarantee that anything posted on platforms like Reddit, Facebook, or Instagram will remain private, even if a group is “closed.”  A member of the group could have a reason for disclosing information outside the group.  All it takes is a screen shot or copy + paste.  Plus, efforts to “de-identify” information do not always work.  Even the smallest bits of supposedly de-identified information can sometimes be pieced together and become identifiable.

There are a variety of legal risks if a post about credentialing or peer review matter gets back to the practitioner who is the subject of the post.  First, the practitioner could claim that the post was defamatory because it disclosed unfavorable information in a public setting.  Also, the practitioner could argue that the post constituted a breach of the confidentiality obligations set forth in the Medical Staff Bylaws, “tortiously interfered” with his employment prospects, or constituted a “breach of contract” under state law.

Social media posts could be problematic even if they are disclosed to individuals other than the practitioner in question.  For example, plaintiffs’ attorneys could use such posts as a reason to look for problems at a hospital.  Also, attorneys representing plaintiffs in malpractice or negligent credentialing cases could argue that the disclosure of peer review information on social media resulted in a waiver of the peer review privilege under state law of any information related to that matter.

So, we want to be careful here.  Again, we don’t mean to discourage professional interactions among Medical Staff professionals.  There are certainly many topics that could be discussed that don’t raise the potential problems discussed above.  However, recognize that there are risks to disclosing practitioner-specific information on social media.

If you have a quick question about this, e-mail Mary Paterni at mpaterni@hortyspringer.com.

January 9, 2025

Posted on by Courtney Patterson

QUESTION:
We have an applicant who is refusing to answer one of the questions on our application form because she says that her lawyer told her it could violate a settlement agreement that she has with another hospital. We think that information is relevant to her request for appointment at our hospital. Can we still ask for the information?  Should we ask for a letter from her lawyer? Should the application be held incomplete?

ANSWER FROM HORTYSPRINGER ATTORNEY LEEANNE MITCHELL:
Yes! Credentialers have a duty to review all of the relevant qualifications of each applicant for Medical Staff appointment and clinical privileges and cannot allow the legal interests of an applicant, in an unrelated matter, to interfere with that duty. Accordingly, the Medical Staff Bylaws (or related policies) should state very clearly that every applicant bears the burden of submitting a complete application and of producing information deemed adequate by the hospital for a proper evaluation of current competence, character, ethics, and other qualifications and for resolving any doubts.

A similar issue arose in a 1997 case, Eyring v. East Tennessee Baptist Hospital, 950 S.W.2d 354 (Tenn. Ct. App. 1997), in which a physician applicant refused to sign a release form authorizing a hospital where he had previously practiced to send information to another hospital where he had applied. The physician argued that he received legal advice that signing the release could compromise his lawsuit against the hospital, which had revoked his privileges. The court held that because the physician had not provided the additional information that the hospital requested – irrespective of the fact that a settlement agreement was in place – he had not submitted a complete application and, thus, under its Bylaws, the hospital was not required to process his application further.

If you have a quick question about this, e-mail LeeAnne Mitchell at LMitchell@hortyspringer.com.

December 5, 2024

Posted on by Courtney Patterson

QUESTION:
It was mentioned that we can expedite the credentialing and privileging of telemedicine providers by using a process that would allow us to rely on the credentialing and privileging of telemedicine providers at another facility. Have you heard of this process?

ANSWER FROM HORTYSPRINGER ATTORNEY HALA MOUZAFFAR:
The process you’re describing is an option CMS has put in place to give healthcare facilities an expedited process to credential and privilege telemedicine providers. It allows your facility to rely on the credentialing and privileging of a provider at another site, also called the distant site, to credential and privilege them at your own facility. To use this process, first and foremost, you must ensure that the entity that is serving as the distant site is either a Medicare-participating hospital or a telemedicine entity that furnishes services in compliance with the Medicare Conditions of Participation.

From there, CMS requires that you have an agreement with the distant site, and then details what must be outlined in that agreement, including a list of the telemedicine provider’s privileges at the distant site, assurance that the telemedicine provider has privileges in the state where patients will be located, and mention that the distant site will receive performance review information of a provider’s privileges.

If this is a process your facility is interested in using, it is worth a deeper dive into those CMS requirements. But before you use this process, I highly recommend your facility have a discussion on whether this process is right for you. It is a big act of trust relying on another facility’s credentialing and privileging process as opposed to your own. You want to have a candid discussion on if this is something you will do for every telemedicine provider, if this is a process you will limit to only certain distant sites, etc.

Additionally, depending on your accrediting body (e.g., the Joint Commission, DNV, etc.), there may be some additional requirements that the distant site may have to meet to be eligible for this process, so don’t forget to check accreditation standards as well.

If you have a quick question about this, e-mail Hala Mouzaffar at hmouzaffar@hortyspringer.com.

September 5, 2024

Posted on by Courtney Patterson

QUESTION:
An applicant’s background check revealed a recent misdemeanor arrest that the applicant failed to disclose on their application. Are we allowed to ask the applicant questions about the arrest even though the background check indicated that the case has not yet been resolved?

OUR ANSWER FROM HORTYSPRINGER ATTORNEY HALA MOUZAFFAR:
Absolutely!

It is the hospital’s responsibility, through the credentialing and privileging process, to appoint only highly qualified providers.  To do so, the burden should be on the applicant to demonstrate current clinical competence and an ability to practice safely.  Therefore, it is important to keep the burden on the applicant to resolve any doubts related to their qualifications.  This includes answering additional questions and resolving any doubts that may come up in the course of reviewing their application.  An application that has red flags or outstanding questions should not be processed further until the underlying issues are resolved to the satisfaction of the hospital.

An arrest, for instance, is something that would certainly require follow-up.  Specifically, when was the arrest? Why was the applicant arrested? Were any charges brought against the applicant? Why did the applicant leave this information out of their application? These are questions for the applicant to resolve prior to the hospital processing the application further.

It does not matter if the applicant’s criminal case has not yet been resolved.  The hospital has the ability to ask those questions it feels need to be answered, and for documentation to support those answers, in order to properly resolve any questions about the applicant, and in this case their arrest.

March 21, 2024

Posted on by Courtney Patterson

QUESTION:
We have an applicant who is refusing to answer one of the questions on our application form because she says that her lawyer told her it could violate a settlement agreement that she has with another hospital.  We think that information is relevant to her request for appointment at our hospital because it involves actions on appointment and privileges.  Can we still ask for the information?  Should we ask for a letter from her lawyer?  Should the application be held incomplete?

OUR ANSWER FROM HORTYSPRINGER ATTORNEY LEEANNE MITCHELL:
Yes! Credentialers have a legal duty to review all relevant information that has any bearing on the qualifications of an applicant for Medical Staff appointment and clinical privileges and cannot allow the legal interests of an applicant, in an unrelated matter, to interfere with that duty.  Accordingly, the Medical Staff Bylaws (or related policies) should state very clearly that every applicant bears the burden of submitting a complete application and of producing information deemed adequate by the hospital for a proper evaluation of current competence, character, ethics, and other qualifications and for resolving any doubts.

A similar issue arose in a 1997 case, Eyring v. East Tennessee Baptist Hospital, 950 S.W.2d 354 (Tenn. Ct. App. 1997), in which a physician applicant refused to sign a release form authorizing a hospital where he had previously practiced to send information to another hospital where he had made an application.  The physician argued that he received legal advice that signing the release could compromise his lawsuit against the hospital, which had revoked his privileges.  The court held that because the physician had not provided the additional information that the hospital requested – regardless of the fact that a settlement agreement was in place – he had not submitted a complete application and, thus, under its Bylaws, the hospital was not required to process his application further.

If you have a quick question about this, e-mail LeeAnne Mitchell at LMitchell@hortyspringer.com.

November 30, 2023

Posted on by Courtney Patterson

QUESTION:
Our hospital is part of a regional system, and while there had been some low-level discussions about whether we may want to have a unified medical staff, the consensus was that we aren’t there yet – however, there is a strong desire for our medical staff processes to become more integrated even if unification isn’t our ultimate outcome.  Are there options short of formally becoming one unified medical staff?

OUR ANSWER FROM HORTYSPRINGER ATTORNEY LEEANNE MITCHELL:
Absolutely!  While one of the main objectives of medical staff unification is consistency in core processes such as credentialing, privileging and peer review – with the goal towards promoting a single standard of care and reducing the administrative burden for the medical staffs and their leaders – many of these benefits can be obtained even in the absence of a unified medical staff.

A good first step is having similar (or identical) policies for credentialing, privileging and peer review at each system hospital that use the same eligibility criteria for appointment and privileges and the same process for evaluating applications among similar types of hospitals.  The same is true for policies governing clinical peer review, professionalism and health.  Consistent bylaws, policies and procedures across the system help the medical staff leaders to do their jobs, and are also helpful for members of the medical staffs who may practice at more than one system hospital to know what the rules are.

Even if a system has the same process for credentialing, privileging and peer review and has adopted the same standards for these activities, there remains the potential for different outcomes when different committees are making decisions.  Steps that the system and its medical staffs can take to address this concern – short of unification – include things such as:

  • Utilizing a central Credentials Verification Office to ensure each medical staff gets the same information about applicants;
  • Utilizing a system (or regional) Credentials Committee, which includes representation from all relevant hospitals, to avoid inconsistent recommendations being made by individual Credentials Committees on practitioners who are applying to more than one system hospital. The same goal can be accomplished in the peer review process by utilizing a system Peer Review Committee – a process that can be even more helpful when system hospitals include much smaller facilities that may have fewer individuals able to serve on such committees; and
  • Incorporating provisions into the medical staff bylaws/credentials policies for each system hospital which state that certain types of significant actions that directly implicate a practitioner’s qualifications to practice – such as performance improvement plans, precautionary suspensions, automatic relinquishments and final actions by the board – become effective immediately at each system hospital where the individual practices, unless the automatic action is waived by the “receiving” hospital’s MEC and the Board.

While these steps don’t achieve the same level of consistency that a unified medical staff would, they are definite steps along the “continuum of integration” that most systems are exploring and implementing.  Also, as the medical staff sees these integration steps in action, they can also help to quell the concerns that are sometimes voiced about possible unification and can be good first steps towards that goal.

If you have a quick question about this, e-mail LeeAnne Mitchell lmitchell@hortyspringer.com.

November 9, 2023

Posted on by Courtney Patterson

QUESTION:
As a part of the threshold eligibility criteria in our Credentials Policy, physicians are required to be board certified by a board approved by the ABMS or AOA.  Can we accept certification by a foreign board from a physician who has applied for Medical Staff appointment and clinical privileges?

OUR ANSWER FROM HORTYSPRINGER ATTORNEY CHARLES CHULACK:
This is a complex question since it may implicate other threshold eligibility criteria in your Credentials Policy.  For example, many medical staffs and hospitals also require a physician to have successfully completed a residency and, if applicable, a fellowship training program approved by the ACGME or AOA.  Thus, if a physician is board certified by a foreign board, it may also mean they did not receive their training in a residency approved by the ACGME or AOA and, consequently, do not meet that criterion as well.

Nonetheless, assuming all other threshold eligibility criteria are met, you may accept certification by a foreign board even though your Credentials Policy requires physicians to be board certified by an ABMS or AOA board.  However, you would first have to go through the waiver of threshold eligibility criteria process outlined in your Credentials Policy.  As an alternative, some hospitals with which we work that repeatedly come across this issue have incorporated a process in their Credentials Policy to use when evaluating whether a foreign board meets the standards of their hospital.  They consider whether the foreign board has comparable certification requirements, including those related to: (1) education and training; (2) letters of attestation or reference; (3) licensing; and (4) written and oral examinations.  A hospital may also give consideration to whether the foreign board is accepted by, for example, the relevant board of the American Board of Medical Specialties for purposes of qualifying for board certification in the United States (e.g., members of The Royal Australian College of General Practitioners are eligible to receive initial board certification through the American Board of Family Medicine) and if the Medical Executive Committee has previously determined that the foreign board meets the standards of the hospital.

It is also important to remember that the burden of demonstrating and producing information to support an applicant’s qualifications lies with the applicant.  This should be specifically stated in your Credentials Policy.  Therefore, if an applicant has certification by a foreign board, the burden is on them to provide information related to the factors described above for evaluating whether the foreign board meets the standards of the hospital.  If you have a quick question about this, e-mail Charlie Chulack at cchulack@hortyspringer.com.

October 26, 2023

Posted on by Courtney Patterson

QUESTION:
A new physician in a difficult to recruit specialty just fell into our laps.  When I asked my lawyer to prepare an Employment Agreement with a November 1, 2023 Starting Date, I was sent an agreement with a number of conditions that cannot possibly be completed in a week. Why must lawyers make these things so complicated?

OUR ANSWER FROM HORTYSPRINGER ATTORNEY HENRY CASALE:
Your lawyer is doing you a favor.

The beginning of an employment relationship is not a simple matter.  The Employer must staff and equip an office for the new physician.  Not something that can be typically done in a week.  However, even if there is sufficient space and personnel for the new physician’s practice, don’t forget that all new employees, including physicians, must complete all required pre-employment screens – that takes time.

But what is often overlooked at the beginning of the legal relationship between a physician and his/her Employer is that since the Employer will be legally obligated to begin to compensate the physician as of the starting date of the agreement, as of that date, the Employer needs to make sure that the physician can perform all of the duties that are set forth in the agreement and (most important to the Employer) that the Employer will begin to be paid for the professional services that are provided by the new physician.

Many commercial insurers take 60-90 days to “credential” a new physician.  They also typically take the position that they have no legal obligation to reimburse the Employer for the professional services that are provided by that physician to the third party’s enrollees until that credentialling process has been completed.  If this process is not timed correctly, the Employer could be on the hook for up to three months of the physician’s salary with no revenue to cover that cost.

But let’s now look at the fact that a physician in a needed specialty fell into your lap.  I am not saying that this can never happen – but it is more likely than not, that this physician found themself in a situation where they were terminated from their old job and needed a new one fast.

You won’t know whether you are lucky, or stuck with a problem physician, until the Employer and the hospital’s credentialling processes have been completed.  Again, this takes time – time that is well spent!

Just as the Employer wants to be paid for the new physician’s services on their first day of employment, the Employer will also want that physician to be able to exercise clinical privileges as of that date as well.  That cannot happen unless the Agreement states that the Agreement does not begin until the hospital credentialling process has been successfully completed.

That is why we advise our clients that hiring is a process.  It takes time.  While you must be flexible, most hires require 60-90 days’ advance notice to set up the physician’s practice, to complete pre-employment screens, to credential the physician with third-party payers, and to allow sufficient time to complete the medical staff credentialling process.  The Agreement should require all of this to be completed by a date-certain, which is also the “Starting Date” of the Agreement and the date that the Employer has the legal obligation to begin to compensate the physician.

The Agreement should also specifically provide the Employer with the right to cancel the Agreement if the physician fails to complete this process in a timely manner, especially if that delay is caused by a clinical or behavioral concern that is discovered during the medical staff credentialling process.

While it is lawful to pay a reasonable signing bonus to a physician as soon as the physician signs on the dotted line, it is preferable not to be obligated to make any kind of upfront payment until the physician is on site and has begun to provide services as your employee.  However, if a signing bonus is paid before the physician begins to provide services, then the Agreement should make it clear that that upfront money must be repaid if the physician fails to start when required by the Agreement.  It is also a good idea to pro-rate the signing bonus so that a portion of that payment must be repaid if the physician does not remain employed for a minimum period of time.

If you have a quick question about this, e-mail Henry Casale at hcasale@hortyspringer.com.  If you want an in-depth discussion of Hospital-Physician employment relationships, compensating physicians and APPs, the Fraud and Abuse laws, the False Claims Act and much more, join me, Dan Mulholland and Hala Mouzaffar in Phoenix from November 16-18, for our Hospital-Physician Contracts and Compliance Clinic.