June 20, 2019

QUESTION:              I noted that one of the cases that was in this week’s HLE arose as a result of a hospital granting temporary privileges to an applicant for medical staff appointment.  While we do not routinely grant temporary privileges, they are useful from time to time.  How much risk is there in granting temporary privileges?


ANSWER:                 While temporary privileges should not be routinely granted, it is not unusual for a hospital’s medical staff bylaws to state that temporary privileges may be granted to applicants for initial appointment whose complete application is pending review by the Medical Executive Committee and the Board. In order to be “complete” there must be verification of licensure, training or experience, current competence, and an ability to perform the privileges requested. In addition, the bylaws should state that in order to be eligible for temporary privileges, an applicant must (i) have had no current or previously successful challenges to licensure or registration, (ii) have not been subject to involuntary termination of medical staff membership at another organization; and (iii) have not been subject to involuntary limitation, reduction, denial, or loss of clinical privileges.   The bylaws may include other criteria that must be met before temporary privileges are granted.

Additionally, the hospital must query and evaluate information from the National Practitioner Data Bank and check the Office of Inspector General’s List of Excluded Individuals/Entities before temporary (or any privileges) can be granted.  Finally, the grant of temporary privileges should be time limited consistent with the standards of the applicable accreditation organization.  According to The Joint Commission standard “Temporary privileges for applicants for new privileges are granted for no more than 120 days.” 

It is not clear, but it appears from the facts of the case described above, that the hospital’s hospitalist group had such a need for the nocturnist that it wanted to use temporary privileges to rush a candidate through the hospital’s credentialing process.  The temporary privileges were granted and rescinded in 2012, but the litigation did not end until 2019.  In this case, not only did granting temporary privileges fail to fill the nocturnist position, but also caused the hospital years of litigation.

The best way to avoid these kinds of situations and the endless litigation that sometimes ensues is only to grant temporary privileges to applicants after a thorough vetting, after confirmation that there are no red flags and only under the above-described circumstances.

March 14, 2019

QUESTION:        We are part of a five-hospital system.  Many of our physicians practice at multiple hospitals in our system.  We’ve had a couple of occasions lately where one hospital addressed a problem applicant or a problem physician, but the physician just moved to another hospital in our system.  We are separate hospitals and separate medical staffs.  We have an information sharing agreement and that helps, but we’re not sure it’s enough.  Can you help?


ANSWER:            You’re off to a good start with an information sharing agreement.  That should allow you to share confidential peer review information between and among your sister organizations.  There is also language you can add to your bylaws or credentials policy (bylaws documents) that can help.  For instance, we recommend threshold eligibility criteria that would render someone ineligible if he or she had staff appointment or privileges “denied, revoked, or terminated” for reasons related to clinical competence or professional conduct at any hospital or health care facility, or had resigned appointment during an investigation, or had an application for appointment not processed due to an omission or misrepresentation.  These threshold eligibility criteria apply not only at appointment and reappointment but during the term of appointment and your bylaws documents should make it clear that failure to satisfy these criteria during appointment will result in an automatic relinquishment.

It is also helpful to have language in your bylaws documents that makes it clear that certain actions, such as a performance improvement plan, automatic relinquishment, or professional review action, when taken at one hospital in the system will be automatically effective at all of the other hospitals in the system.  The bylaws language should allow for a waiver by the Board, upon the recommendation of the appropriate Medical Executive Committee, when it would not be necessary or appropriate for the action to be effective at any given hospital.  This language gives you some wiggle room and some discretion, but it also helps ensure that you are not caught up in redoing peer review efforts, including investigations and hearings, at multiple hospitals in the system.  Fortunately, there is helpful language in the National Practitioner Data Bank Guidebook which makes it clear that administrative actions taken by hospitals in a system based exclusively on the action taken at a sister hospital should not be reported to the NPDB.

February 7, 2019


QUESTION:        When a health care provider obtains a self-query from the National Practitioner Data Bank (“NPDB”), does the self-query indicate how many times a hospital itself has queried that provider?


ANSWER:            The short answer is that, in limited circumstances, this information will be included in the self-query for the health care provider.  The NPDB discloses all reports about a health care practitioner to hospitals that submit queries about that practitioner and, as a result, those disclosures are indicated on the self-query.  That information is available to the practitioner and contained in the self-query as part of the disclosure history.  However, if there are no reports to be disclosed about a health care practitioner, the NPDB does not inform the individual of the hospital queries, as no disclosures were made.

Federal law provides that the NPDB collect information and maintain reports on medical malpractice payments, federal and state licensure and certification actions, adverse clinical privileges actions, adverse professional society membership actions, negative actions or findings by private accreditation organizations and peer review organizations, health care-related criminal convictions and civil judgments, exclusions from participation in a federal or state health care program (including Medicare and Medicaid exclusions), and other adjudicated actions or decisions.

The reports maintained by the NPDB are disclosed upon query to hospitals, which are mandated by federal law to submit such queries at the time the health care practitioner applies for a position on its medical staff or clinical privileges at the hospital and every two years for any health care practitioner on its medical staff or with clinical privileges at the hospital.  According to the NPDB, when the hospital submits a query, the NPDB releases only the information it is lawfully allowed to access.  A hospital can query through the NPDB using a one-time query, which allows for a one-time query response for a practitioner, or a continuous query, which allows the hospital to receive a query response and all new or updated report notifications during the year-long enrollment for each practitioner.

Also available through the NPDB is a self-query, which can be submitted by a health care practitioner about his or her own information kept by the NPDB.  The self-query searches to determine if the health care practitioner’s own information provided matches information in reports previously submitted to the NPDB.  The response may show that no matching information was found in the NPDB, or it may show that information about medical malpractice payments, adverse licensure or privileges actions, or judgments and convictions was found, in which case the full report(s) will be provided to that health care practitioner as part of the self-query.

In the instance a health care provider submits a self-query and no matching information or reports are found, the health care provider will not see how many times any hospital has queried that provider.  However, when there are reports returned on a health care provider, the self-query will not necessarily show how many times that provider was queried, but will indicate how and who the reports were disclosed to when that provider was queried.

November 1, 2018

QUESTION:        We are considering having a Credentials Verification Organization (“CVO”) perform primary source verification and other required verifications for our credentialing process.  Do we need to have some sort of agreement in place?  If so, what should that agreement include?

ANSWER:            Regardless of whether you are using an internal CVO (i.e., one that is a part of your organization) or an external, independent CVO (i.e., one that has no corporate affiliation with your hospital), there should be an agreement in place between the CVO and the hospital.

An agreement should define the obligations of the CVO, including the services that it will provide.  The agreement should also specifically identify the information that will be verified and the sources that will be used for verification purposes.  If ongoing monitoring of practitioners’ credentials is a part of the services the CVO will provide, the agreement should state this and indicate the credentials that will be monitored (e.g., Medicare and Medicaid sanctions and exclusions).

Furthermore, sharing of confidential credentials information should be addressed and include provisions on how sensitive information such as National Practitioner Data Bank reports and drug or alcohol treatment information will be handled and shared.  If the hospital is involved in delegated credentialing for third-party payors, there are special considerations for sub-delegation agreements, which would include agreements with an external CVO to perform verification activities.

Specifically, the agreement must require semiannual reporting of the CVO to the hospital on its conduct of the contracted-for activities, describe the process by which the hospital evaluates the CVO’s performance under the agreement, and describe the remedies available to the hospital if the CVO does not fulfill its obligations, including revocation of the delegation agreement.

May 31, 2018

QUESTION:        The case description in McGary v. Williamsport Reg’l Med. Ctr. references the fact that a hospital “denied” a physician’s application for failure to meet threshold eligibility criteria.  Is that really a “denial”?  Isn’t there a better way?

ANSWER:            YES, there is a better way.  Medical Staff bylaws or credentials policies should clearly incorporate the concept of “eligibility” to apply for appointment and/or clinical privileges and should include a comprehensive list of objective eligibility criteria that must be met in order for an applicant to be considered eligible.  The threshold eligibility criteria should address both appointment qualifications (things like not having had a license revoked by a state agency) as well as privilege qualifications (things like the volume requirements at issue in the case, or additional certifications).   The provision should clearly allow for the determination that an applicant is not eligible for appointment and state that applications from individuals who do not meet the threshold eligibility criteria will not be processed.

Incorporating such a step into the bylaws would require that individuals who request applications be sent a request for application form that outlines, in detail, the threshold eligibility criteria for appointment, and requests that the applicant provide proof that he or she meets those threshold criteria.  Alternatively, if the idea of incorporating a two-step request for application process is too onerous, this could also be accomplished by sending a detailed cover letter with the application form that sets out the eligibility criteria.  Those individuals who do not meet the “threshold” criteria for Medical Staff appointment and clinical privileges should be informed that they are ineligible to receive an application or to apply for staff appointment and privileges.  The bylaws should also clearly state that a determination that someone is ineligible to apply is not a “denial” of appointment that entitles the individual to a hearing, nor is it reportable to the state licensure agency or the National Practitioner Data Bank.


April 26, 2018

QUESTION:        We have an orthopedic surgeon who is applying for appointment and clinical privileges at our system who has a troubling malpractice history.  Within the past five years, he has settled three malpractice claims ($190,000, $100,000, and $75,000).  He also has two other cases that are pending.  We are reluctant to grant him appointment.  At the same time, we are not sure if we have enough to deny his application. What should we do?

ANSWER:            Malpractice claims can be tough sometimes.  A single claim, standing alone, does not necessarily indicate a problem. However, multiple malpractice claims may reflect underlying issues pertaining to judgment, skill, communication, or behavior, all of which are relevant considerations for appointment and clinical privileges.

Furthermore, according to a study by the New England Journal of Medicine, only 4% of physicians had three or more malpractice claims.  The risk of recurrence of a malpractice claim increases with the number of previous paid claims.  Physicians who have three paid claims had three times the risk, or a 24% chance, of another paid claim within two years.  According to a Vanderbilt University study, physicians with past records of malpractice claims can be expected to have “appreciably worse claims experience” than other physicians in future years.

You can also review relevant data available from the National Practitioner Data Bank, which includes medical malpractice payments by practitioner type and state.  This may help to put your applicant’s malpractice history in perspective.  Malpractice history, including judgments and settlements, is also important because it could be used against the hospital in a negligent credentialing case if the physician were appointed and then subsequently was sued.

Therefore, before you move forward with the application, you should require the applicant to resolve the concerns raised by his malpractice history.  One way to review and assess the concerns would be to review the underlying malpractice cases through your peer review process or to use an expert from an external peer review organization for this purpose.  Since the burden of resolving questions about qualifications is on the applicant, the applicant should be responsible for providing a copy of the medical records from the malpractice claims.  The applicant would also be responsible for any costs associated with this review.

Remember to keep the burden on the applicant to resolve your concerns.  If the concerns cannot be resolved, you may determine that the application is incomplete and should not be processed.  Denying the application is a last resort that is almost never needed.

August 17, 2017

QUESTION:        The Chief of Staff recently implemented a precautionary suspension after a Medical Staff member engaged in some seriously unprofessional behavior that was thought to compromise patient safety.  The MEC met to review the matter and lifted the precautionary suspension after four days.  A formal investigation was commenced and that process is now complete and the MEC is considering suspending the practitioner for 30 days.  For purposes of reporting to the National Practitioner Data Bank (NPDB), will that suspension be added to the four-day suspension he already served — meaning that it will constitute a 34-day suspension and will, in turn, become reportable to the NPDB as a suspension lasting more than 30 days?

ANSWER:            Even though the precautionary suspension and the “regular” suspension are related to the same factual matter, they are separate professional review actions and, in turn, they do not “add up” for the sake of reporting.  Therefore, the four-day precautionary suspension was not reportable to the NPDB.  The same will be true of a 30-day suspension, if that action is finalized by the Board.  Be sure to check the applicable requirements of state law, however, as some states require hospitals to report all suspensions of clinical privileges, no matter how long they last.

October 27, 2016

QUESTION:        We have an applicant who had significant issues at the last hospital where she practiced, significant enough that she left while under investigation.  The NPDB report provided us with very little information, really only enough to know that the matter appeared to involve behavior and not clinical care, but it certainly was not enough to feel like we know what happened.  The hospital won’t respond to our requests for information, and when we formally asked the applicant for additional information, her lawyer sent us a letter telling us she is bound by a “legally binding” settlement agreement not to disclose what happened except that she had decided not to pursue the investigative process.  What can we do?

ANSWER:            This is a classic example of an incomplete application.  Settlement agreement or no, you should advise the applicant that she has the burden of producing information sufficient to evaluate her qualifications.  You can agree to keep any information provided to you by the applicant, and by the other hospital, confidential for use in your credentialing process only.  However, you cannot process this application without some information to determine the basis for the physician’s resignation while under investigation.  If she does not provide the information within a reasonable time, you can advise her that her application will be deemed to have been withdrawn.  It is helpful to have very clear and direct language in the Medical Staff Bylaws to emphasize that the burden is on the applicant to provide information necessary to assess qualifications, as well as a statement that incomplete applications will not be processed.  Don’t be dissuaded by the existence of a settlement agreement – the courts have supported the need to obtain information relevant to the credentialing process.

In Scott v. Sisters of St. Francis Health Services, 645 F. Supp. 1465 (N.D. Ill. 1986), St. James Hospital refused to forward Dr. Mac Scott’s application to the Credentials Committee because it had been unable to obtain information regarding his suspension and subsequent resignation from the medical staff of Ingalls Hospital.  Dr. Scott had sued Ingalls Hospital and, as part of a settlement agreement, the hospital could only respond to inquiries about Dr. Scott with a form letter prepared by Dr. Scott’s attorney, which provided no meaningful information upon which to make a recommendation regarding appointment.

Dr. Scott sued, alleging:  (1) that the refusal to forward his application to the Credentials Committee was a violation of his civil rights and racially motivated; and (2) that the hospital president had exceeded her authority by refusing to forward the application.  The federal district court rejected those arguments and entered judgment in favor of the Sisters of St. Francis Health Services, stating:

Scott’s assertion, however, does not take into account the fact that the bylaws provide that Sister is to forward only completed applications to the Credentials Committee for consideration.  Sister discussed with Scott the problems he experienced at Ingalls and the need for additional information from Ingalls about his suspension.  Sufficient evidence was presented at trial to show Scott’s application was incomplete, and Scott’s efforts prevented St. James from obtaining needed information from Ingalls.  As such, Sister’s decisions to not forward Scott’s applications were not outside the bounds of her authority as President of St. James nor indicative of any intent to discriminate against Scott on the basis of his race.  [Emphasis added.]

Additional cases that have held that a hospital has no duty to process an incomplete application include Evers v. Edward Hospital Association, 617 N.E.2d 1211 (Ill. Ct. App. 1993), and Eyring v. East Tennessee Baptist Hospital, 950 S.W.2d 354 (Tenn. Ct. App. 1997).  (While Scott and Evers involved the initial credentialing process, Eyring was a reappointment case.)

May 19, 2016

QUESTION:        Our hospital is registered with the National Practitioner Data Bank (“NPDB”).  We would like to designate as an authorized agent for NPDB querying purposes a credentials verification organization (“CVO”) with which we have recently started working.  How do we go about doing this?

ANSWER:           The NPDB explicitly permits the practice of eligible entities, including hospitals, designating authorized agents, such as CVOs, to query on their behalf.  However, according to the NPDB Guidebook, an authorized agent must, itself, register with the NPDB and comply with all the registration requirements.  Often, CVOs act as authorized agents for a number of eligible entities.  Nonetheless, the CVO must query the NPDB separately for each eligible entity they represent.  Moreover, the CVO is not permitted to share results of a query for one eligible entity with another eligible entity.

After the CVO registers with the NPDB, your hospital will have to designate the CVO as its authorized agent.  This is a relatively simple process that can be done electronically by accessing this web address:  https://www.npdb.hrsa.gov/hcorg/howToDesignateAnAuthorizedAgent.jsp.  Finally, as a part of designating the CVO as an authorized agent to query the NPDB on behalf of your hospital, you will have to create a written agreement between your hospital and the CVO.  The NPDB Guidebook does not identify any required elements for this written agreement, but the NPDB website provides recommendations for what should be included in the agreement.  According to the NPDB website, the agreement should confirm the following:  (1) the authorized agent is authorized to conduct business in the relevant state; (2) the authorized agent’s facilities are capable of maintaining the security and confidentiality of NPDB reporting and query responses; (3) the authorized agent is prohibited from using querying responses for any purpose other than that for which the disclosure was made; and (4) the agent understands that sanctions can be taken if information is requested, used, or disclosed in violation of NPDB provisions.

March 19, 2015

QUESTION:        In this week’s “NEW CASES,” I see that the U.S. Court of Appeals for the 7th Circuit held that a Chief of Staff’s discussion with an applicant about the red flags in his application and the consequences of denial (reporting to the NPDB) constituted an adverse employment action. Should we immediately halt all such conversations?

ANSWER:        No – you do not need to immediately halt informal discussions with applicants regarding the concerns you have about their applications. Nor need you stop educating applicants and medical staff members about the credentialing process and its intricacies. HOWEVER, as always, you should be careful about the legal implications of how you communicate regarding these matters.

First, let’s look at how the Seventh Circuit described the conversation between the Chief of Staff and Dr. Simpson (internal citations omitted):

Dr. Eric Miller [The Chief of Staff] called Dr. Simpson to give him a “heads-up” about the Credentials Committee’s concerns about his application for medical staff privileges. Eric Miller explained to Simpson that if his application were to be denied, it would have to be reported to the National Practitioner Data Bank. Eric Miller outlined some of the Committee’s concerns, including Simpson’s employment and education history, the need to take an oral exam to obtain licensure from the state of Wisconsin, the two malpractice lawsuits, and interpersonal communications. Eric Miller wanted to give Simpson an opportunity to withdraw his application and avoid the risk that a denial would have to be reported to the National Practitioner Data Bank.

* * *

Dr. Eric Miller accused him of “disruptive behavior,” referring to his interaction with [the CEO] when he attempted to get his sign-on bonus. Eric Miller told Simpson that he would have expected an applicant to be on his “best behavior” and more “collegial” during the pendency of his application for medical staff privileges. Simpson suggested that [the hospital] hire him on a probationary status to see how he would do if Eric Miller was concerned that he was disruptive. Eric Miller responded that they had had some “bad actors” in the past, and it was easier not to hire a bad actor than to get rid of one. Simpson also stated that Eric Miller said he wished Simpson well in finding a position that was a “better fit.”

* * *

We agree that Dr. Simpson has suffered an adverse employment action. To establish an adverse employment action, “a ‘plaintiff must show that a reasonable employee would have found the challenged action materially adverse.’” A reasonable physician would have found the threat that his application for privileges would be rejected and that the rejection would have to be reported to the National Practitioner Data Bank to have been materially adverse. While an applicant who voluntarily withdraws an application cannot state a prima facie case of discrimination, Dr. Eric Miller’s warning indicated that it would be futile for Simpson to maintain his application. The writing was on the wall. In essence, viewing the facts in the light most favorable to Simpson, he was compelled to withdraw his application for privileges before the Credentials Committee voted on it; thus the withdrawal does not undermine his prima facie case.

It is clear that, based on the evidence at hand in the Simpson case, the Seventh Circuit believed that the Chief of Staff had not only educated Dr. Simpson about the credentialing process, the concerns with his application, and the consequences of any potential denial – but, also had impressed on Dr. Simpson that his application would, in fact, be denied.

So, what can be learned from this opinion? First, always have more than one person present if you are going to have this sort of discussion with an applicant. That way, you won’t run into a “he said – she said” type of situation.

Secondly, always document these conversations. Documentation serves as great evidence of what was really said years later, when memories have faded. A good way to create the necessary documentation is to follow up in writing, with a letter to the applicant, thanking him or her for talking with you and then outlining briefly the content of your discussion.

Third, never imply or express that the outcome of a credentialing matter has been decided when it has not. Dr. Simpson came away from his conversation with the Chief of Staff believing that he had been told that his application would be denied and he would be reported to the Data Bank, so it would be better for him to go somewhere else where he could fit in better. This is despite the fact that his application was still on hold at the Credentials Committee level of review (it was incomplete due to missing pieces of information). And, though there were a number of unresolved red flags that were part of his application, there was no reason, at the time the Chief of Staff called him, for anyone to conclude that Dr. Simpson would complete his application sufficiently to have it processed or, in the event that he did complete the application, that it would be denied.

Fourth, to make sure that you choose your words carefully and don’t give the wrong impression, prior to having this type of meeting with an applicant, consult with hospital legal counsel and other medical staff leaders involved in the credentialing process. Then, based on those conversations, create a checklist of items to be discussed with the applicant and use that checklist as the talking points for your conversation. Finally, have legal counsel review any follow-up letter, to be sure that any points of confusion are ironed out in that letter. That way, everyone can be clear that a “heads-up” conversation is just that – a heads-up to the applicant about the current status of his or her application, the immediate next steps in the process, and the details of the credentialing process that lies ahead, including any possibly unexpected consequences (such as reporting to the NPDB).