QUESTION:        We are currently in the process of adopting new Medical Staff Bylaws. A member of the Medical Staff questioned whether language that was included in the draft Credentials Policy indicating that the appropriateness of utilization patterns would be considered when granting privileges would constitute “economic credentialing.” Does it?

ANSWER:           Not in our experience. This type of language is often included in medical staff documents to allow for consideration of patterns related to comparative lengths of stay, medical necessity issues, and similar matters. The purpose is not to exclude someone from the medical staff; rather, it is intended to allow for performance improvement. For example, if someone was an outlier in length of stay, as compared to his or her peers, that variance would be something that could be addressed as a part of the Ongoing Professional Practice Evaluation (“OPPE”) process. Such a scenario would only result in “economic credentialing” if the data was used to serve as the basis for revoking that physician’s clinical privileges.

Interestingly, the Final Rule related to the new Comprehensive Care for Joint Replacement (“CJR”) bundled payment model highlighted in this week’s Government at Work includes a question about the effect such programs might have on credentialing, being that they encourage hospitals to use only the most “efficient” or “cost-effective” physicians. While CMS indicates that existing antitrust laws may limit a hospital’s ability to keep privileges from a non-compliant or high-cost physician, it does not include any restrictions that would specifically prohibit a hospital from doing so.

Please join LeeAnne Mitchell and Ian Donaldson at an upcoming Credentialing Clinic to learn more about the new wave of credentialing matters facing Medical Staff leaders. You can join us for this interactive course by clicking here.