I was curious about the FTC’s and other federal agencies regulations requiring compliance with The Red Flag Identity Theft Rules. At first I didn’t think it applied to hospitals but further explanation clarified that “organizations providing services on a deferred payment basis would be considered “creditors” and, therefore, would be included in the new regulations.

As my mind often wanders when reading such interesting articles, I recalled a recent event when an employee had her identify “stolen” which resulted in her employer being ordered by the court to withhold her salary. Fortunately the employee was able to prove in court that she was not the individual who had committed the fraud and her salary was returned to her. Does this happen to physicians? Do they have to worry about identify theft?

It should not be a surprise to MSPs that there are many instances of Medicare fraud. One story relates information being collected from physicians for a “CMS file update”. This information was then used to submit false Medicare claims. For example Mailee Renae Lodge, AKA Mailee Renae Reed, was ordered to pay $1.3 million in restitution and was sentenced to 5 years in prison for billing for home examinations, sleep studies and pulmonary studies using stolen provider ID to fraudulently bill.

In another example, California’s state Medicaid program was defrauded $3.9 million by the use of physicians’ stolen identities. Some of the criminals were arrested and charged but often the perpetrators are never found.

Worried about Identity Theft? I’ll bet your physicians are.

Carole La Pine, MSA, CPMSM, CPCS

It’s probably a very good thing I didn’t pursue a legal career. My personality type wants to see the various graduations between black and white, not merely the distinction between the two. In the Kadlec case, for example, the first decision held the Lakeview Medical Center and the Lakeview Anesthesia Associates accountable for reporting the drug problem of Dr. Berry. This was a clear, concise decision. However, that decision was recently reversed stating that the hospital and group practice did not have a duty to disclose such information. This has left MSPs wondering what our duty is now when we are asked to disclose information about previous medical staff members.

We have gone from a black/white decision to one being very gray. It is this “gray” area that I welcome for a number of reasons. First, it gets all of us thinking and asking ourselves “what would I do?” Second, we can also ask ourselves “what’s in the best interest of our patients?” It also gives us an opportunity to discuss this issue with our legal counsel as well as our medical staff leaders.

After considering these questions, are you clear on how you would handle a request for information regarding someone like Dr. Berry?

Not familiar with the Kadlec case? There is a great deal available via the Internet: Click here for an interesting article.

Carole La Pine, MSA, CPMSM, CPCS

Last week I was lucky enough to attend the annual National Association Medical Staff Services (NAMSS) conference in Milwaukee, WI. As always, it was a pleasure to meet Briefings on Credentialing readers in person and hear what you’d like to read about in the newsletter. I attended several informative sessions ranging from CVO best practices to managing AHPs. Outside of the conference I enjoyed myself as well. On Monday night I attended a reception at the Pabst Mansion hosted by the CACTUS Software group, and I brought home some great souvenirs including cheese in the shape of a motorcycle (Milwaukee’s home to the Harley-Davidson Museum) and photographs of the “Bronzie Fonzie” statue from the television show Happy Days.

What was your fondest memory from the conference? Did you meet up with friends from past conferences or make new connections? Which session really opened your eyes and presented you with the solution you were looking for? Did you miss the conference but want to hear about the new hot topics? I invite you to share your memories with others by posting your comments below.

Best wishes,
Emily Berry
Associate Editor

A question was posed to me the other day about whether or not there should be a place on the initial and reappointment applications for physicians to indicate their category of medical staff membership.

My response was that we do not allow the physician to make the determination of medical staff membership category on initial application. Rather, the department chair makes the recommendation of the appropriate category based upon the outcome of the interview in which the department chair has the opportunity to discuss practice plans with the applicant. Seeking out this information is particularly important to identify the intended admission plans as well as to have discussion regarding specific inpatient privileges. We are seeing many of today’s applicants arranging for hospitalist coverage for inpatients and not requesting hospital privileges.

During reappointment, the application is pre-populated with the current membership category. If a physician wants to change membership categories, he/she would be required to submit a formal request to the department chair. The change in membership category is then processed via the department, credentials committee, MEC and finally the board. Again, this formal process allows for dialogue between the physician and the department chair regarding hospital utilization plans.

Carole La Pine, MSA, CPMSM, CPCS

Here’s an interesting article on the limitations of MRI scans and issues of competency—and that just because a patient gets one, doesn’t necessarily mean that the correct diagnosis will be made.

Basing the article on her and a colleague’s experience in which significant injuries were not found in early scans, journalist Gina Kolata writes:

Dr. Forman said that at the very least, patients should go to radiology centers accredited by the American College of Radiology. But he added that accreditation does not tell you whether your scan will be done with a machine that is several generations removed from the best available today; whether the scanning is programmed to pick up your particular problem; or whether the receiving coil that picks up signals from the magnet is sufficiently sensitive.

G. Scott Gazelle, a professor of radiology at Harvard Medical School, shared Dr. Forman’s opinions.

“People don’t understand that there are these differences,” he said, adding that radiology centers that do not keep up will be doing a less than ideal job. “The pace of technology development is staggering,” he said.

Then there is the question of how skilled is the radiologist who reads your scans.

Todd Morrison

Managing editor, Credentialing

HCPro, Inc.

The National Association Medical Staff Services (NAMSS) is bringing the famous (or infamous, depending on your opinion) to the annual Conference to be held in Milwaukee, Wisconsin October 13-15. Hunter “Patch” Adams will be the key note speaker to open the conference on Monday, October 13 at 8 am. 

Many of us remember watching the movie, Patch Adams, starring Robin Williams and felt touched by the Doctor’s ability to make illness funny. During that period of time, most physicians did not bring humor to a patient’s bedside and many still don’t today. 

I believe there has been a change in the delivery of healthcare in the past few years, however, since physicians are now being held accountable for patient satisfaction measurements. This is a good thing. 

We may never come across a Patch Adams in our credentialing/privileging responsibilities and perhaps that is as it should be. What do you think about humor in healthcare? 

Carole La Pine, MSA, CPMSM, CPCS

In a conversation several months ago with one of my favorite MSP leaders, we agreed that one of the important elements of our education is missing: Privilege development. For the most part many MSPs focus on accreditation standards, regulatory compliancy, and governance structure. Often we are faced with the responsibility to assist in the development of “core privileges,” specialty privileges or special privileges. Unless we have a nursing background, my guess is that many of us don’t quite understand the terms in our privilege forms or know when a privilege can have multiple names. 

If this is true, then how can we be successful in our roles? Where could or should we go for further education? 

In my experience, MSPs deal with this issues in various ways and with varying degrees of success. Usually our course of action is to contact our peers by email or through forums like MSTalk and ask: “Do you have a privilege form for robotic surgery that you could share with me?” (NAMSS members also use the discussion forum on the NAMSS Web site to request privileging information and criteria.)  Other times, it’s a privilege form for stereotactic radiosurgery (also referred to as “cyberknife”), virtual colonoscopy, sleeve gastrectomies, renal cryoablation, pro disc C cervical disc replacement, etc., etc. Honestly, I wish I knew what half of what these terms meant! 

I don’t think I’ll have time to enroll in a nursing program but I sure would like to increase my knowledge base regarding the above! 

I’d be very interested to hear from you in MSP-land about your need for education in privileging and medical terminology. How important to you is this knowledge? 

Carole La Pine, MSA, CPMSM, CPCS

After reading the news in ModernHealthcare.com that CMS had granted U.S. hospital deeming status to the National Integrated Accreditation for Healthcare Organizations (NIAHO), run by Det Norske Veritas (DNV), I decided to call Robyn Myers, Director of Quality and Accreditation for Atrium.  

Robyn stated the reasons Atrium went with ISO 9001 standards was mainly to improve quality throughout the hospital not just clinical services. After going through training on the ISO philosophy, Robyn spent the next four to five months developing manuals, setting up education sessions, and developing system policies where some were needed.  

I asked Robyn “Why would a hospital want to switch from The Joint Commission or Healthcare Facility Accreditation Program to NIAHO (ISO 9001)”? Here are a few of the reasons: 

ISO keeps the hospital on track everyday, not just at survey time. Although the surveys are somewhat unannounced, there is a three month notice of an upcoming survey.

There is not much variation between surveyors and there is actually a relationship that develops between the hospital and the surveyor so the process is collaborative and not punitive. The public can relate to ISO Standards because those standards can apply to various industries (laboratories, aviation, manufacturing, etc). 

A challenge for Robyn was learning new terminology and teaching hospital staff and medical staff both the language and new concepts. I couldn’t help but ask Robyn about OPPE and FPPE and if that was something she dealt with under ISO standards. Her answer: Not at all. 

Carole La Pine, MSA, CPMSM, CPCS