Medical credentialing is a rigorous process conducted to verify that a healthcare worker (such as a doctor, nurse, or physical therapist) is fit to provide patient care. Credentialing processes examine everything from graduation dates to employment history to licensure, all with the aim of approving only those who will contribute to the wellbeing of patients.
During this process, red flags may arise which indicate that a person's background deserves a closer examination. Failing to investigate suspicious information could result in hiring someone who's unfit to serve patients. These workers can cause problems on your staff and for your patients, and could potentially lead to charges of negligent credentialing.
So, what are the warning signs you should be looking out for? In this guide, we'll give you five common issues that signal additional investigation is needed.
What Is Medical Credentialing?
Medical staff credentialing is a crucial step in providing safe and healing environments for patients. It's more comprehensive than the employee credentialing processes in many other industries. It typically involves primary source verification, which involves contacting and querying primary sources rather than accepting the credentials reported on a resume.
The Importance of Medical Provider Credentialing
Credentialing ensures that those providing patient care are who they say they are, and that they're qualified and competent to administer the treatments they're responsible for. Credentialing is also a legal and regulatory requirement, and helps healthcare facilities receive proper reimbursement from payers.
The Risks of Inadequate Credentialing
Insufficient credentialing can lead to a multitude of problems related to poor patient care, problematic staff dynamics, and legal exposure. Here are some consequences to consider:
- Patient harm and increased incidence of adverse events
- Patient mistrust in the healthcare institution
- Staff with substance abuse disorders
- Staff holding fraudulent degrees
- Malpractice or negligent credentialing lawsuits
- Damaged facility reputation
Medical Staff Credentialing: 5 Red Flags
Credentialing is a highly involved process that scrutinizes healthcare workers' background (personal and professional) to determine competence and trustworthiness. Here are five signs that indicate a provider's background and medical credentials warrant closer inspection and discussion.
1. Unexplained Gaps in Clinical Employment History
Credentialing functions as a safety net that keeps unqualified and incompetent providers away from patients. An unexplained lapse in employment of 30 days or more is a red flag that could indicate that a clinician wouldn't be safe around patients.
Among other things, an employment gap could indicate the provider was dealing with a legal problem or attending rehab, warranting further investigation into the issue. This is why it's common to ask for an explanation for a gap in employment history of 30 days or more.
2. Disciplinary Action Against Against a License
Medical credentialing companies and committees often perform searches of databases to look for past disciplinary actions against licensed professionals. Action against a licensure (for example, a state board of nursing's suspension of an RN license) serves as a warning sign that an individual breached their professional duties in the past.
Credentialing software can also be used to query databases such as Nursys and the National Practitioner Data Bank (NPDB) for past infringements. Previous probations, suspensions, or adverse actions of any kind deserve further investigation. Any conditions imposed on a clinician's medical credentials should also be investigated. For example, if a physician was required to fulfill certain conditions to avoid sanctions from a state board, the credentialing committee should dig deeper into the reason for this arrangement.
3. Medical Malpractice Payments
Malpractice payouts are an important red flag in medical staff credentialing because they point toward clinician behaviors that create legal risk for a healthcare organization. In some specialty areas, malpractice suits come with the territory of practicing. For example, one study found that by age 65, 99% of physicians in high-risk specialty areas had been sued for malpractice. Specialties considered high-risk for legal action include surgery, OB-GYN, and emergency medicine.
When examining warning signs in this area it's important to consider the specialty, the frequency of claims, and the payment amount. A high frequency of claims or significant payouts indicate that a practitioner may be incompetent and unsafe.
4. Termination From a Previous Healthcare Facility
Because the credentialing process is intended to ensure quality patient care, it's important to flag and investigate any instance in which a person was fired. Determine whether it involved patient harm, incompetence, substance abuse, or any other risky behavior that could carry forward.
5. Criminal History, Especially if Healthcare-Related
A history of unlawful behavior, on or off duty, should trigger further investigation. Clinicians with a criminal background may represent a risk to patient safety and wellbeing. Prior convictions indicate a more extensive review should be conducted to assess the provider's moral character, judgment, and integrity. If a clinician’s criminal history pertains to their professional practice of healthcare, this is an obvious red flag that must be carefully scrutinized.
While it may lead to an immediate rejection, if the clinician is presently authorized to practice, there may have been mitigating factors and rehabilitation efforts, but also they likely have a gap in their licensure. All of this information must be carefully reviewed to ensure patient safety.
Get More Healthcare Hiring Resources and Guides
Medical credentialing is a crucial step that will help you hire only the best. Looking for more guidance as you build your healthcare team? Lean on our healthcare leadership resources and guides for helpful and actionable information about managing your high-performing team.