QUESTION:
Our Bylaws state that an individual is not eligible to have his or her application processed if the applicant does not satisfy our threshold eligibility criteria.  Occasionally, this results in an application being held up in terms of processing even though we feel fairly certain that the applicant will – eventually – meet the relevant eligibility criteria.  For example, when a new physician is being recruited to a local group, that individual will often file the application for medical staff appointment prior to moving, in order to get to work immediately upon relocating.  But, since that individual often lacks a home or practice office within the requisite geographic area (close enough to respond to patients), and may lack a coverage arrangement with a member of the Medical Staff, professional liability insurance, in-state licensure, and/or a DEA registration linked to an address within the state (since the local employment arrangement has not yet commenced and/or routine paperwork associated with relocation is still in process), the applicant is ineligible.  Is there any way to prevent unnecessary delays in cases such as these?

OUR ANSWER FROM HORTYSPRINGER ATTORNEY RACHEL REMALEY:
Yes!  Especially with the physician and health care worker shortages that are being faced by so many health care facilities around the country, it is essential to eliminate delays in credentialing – particularly where those delays do not improve quality or patient safety.  Of course, threshold eligibility criteria are incredibly important in administering an efficient and effective credentialing process, but scenarios such as the one you describe can lead to frustration and lost time and money.

All of this can be fixed by incorporating language into the Medical Staff Bylaws or Medical Staff Credentials Policy specifying that applications can be processed, despite the fact that an applicant does not meet a threshold criterion, provided that finalization of any action on Medical Staff membership or Clinical Privileges will be held at bay until such time as satisfactory evidence of the individual’s satisfaction of the relevant criteria is received by the Hospital.  We call this “Processing Applications Pending Resolution of Ineligibility.”

A few important things to note:

• Where an eligibility criterion cannot be resolved, the new language and process would not be invoked and the application would not be processed. For example, if an applicant were a convicted felon, that is not an eligibility criterion that is in the process of being resolved and, in turn, that applicant could easily be informed at the outset that he or she is ineligible and the application will not be processed.  Case closed.

• Credentialing is a time-consuming business – you don’t want to waste the time of your leaders processing applications for individuals who are likely to have a complex resolution to the matter that rendered the individual ineligible. For example, if an applicant had their privileges revoked at the hospital where they last held Medical Staff membership, but has a lawsuit pending against that hospital to challenge the revocation, it would not be wise to process the application pending resolution of ineligibility.  Why?  Amongst other reasons, because doing so would not promote efficiency.  If (and it’s a big IF) the lawsuit were successful and the individual had his or her membership and privileges reinstated at the prior facility (or had a court determine that the other hospital acted wrongfully), while that would render the individual eligible for consideration at your hospital, it would also raise a lot of questions and warrant careful subjective scrutiny of the matter through your credentialing process.  So, even if you had been processing the application pending that judgment, you would still have lots of credentialing work to do (some of which may be repetitive of the work already done on that application).

• In the end, you are most likely to want to generate efficiencies by proceeding with the processing of those applications most likely to move through the process without a hitch once all of the paperwork and logistics are finalized (e.g. those awaiting receipt of a license, where there is nothing in the application to indicate that licensure will be delayed or, alternatively, those who expect to have malpractice coverage on their first day of employment, which will be on an upcoming date with a known group). To achieve this, consider drafting your Bylaws/Credentials Policy language to give your leaders (perhaps the CMO and/or Chief of Staff) some discretion in determining whether an application should be processed – as an exception to the rule – while awaiting resolution of a matter of eligibility.

• Finally, do not forget to include a process for the Hospital to verify resolution of the relevant threshold criteria before finalizing appointment and privileges. To avoid any mix-ups, some organizations draft their language to allow processing of the application only through the MEC recommendation, holding the application at that point until the CMO verifies evidence has been received verifying that the applicant satisfies all eligibility criteria (for example, a copy of the individual’s license or malpractice certificate is submitted).  If any information submitted in furtherance of resolution raises additional concerns about the applicant, the application should be returned to the Medical Staff Office for consideration and should go back through the credentialing process for this new information to be considered as part of the application (this could occur, for example, if the individual provides proof of having received his or her in-state license, but that licensure is subject to conditions).

If you have a quick question about this topic, feel free to e-mail Rachel Remaley at rremaley@hortyspringer.com.