Consequences of Poorly Managed Credential Files

- August 26, 2015 -

Harmful quality issues and poor patient experiences can arise when a surgery center’s credential files are mismanaged and noncompliant. As an important part of facilities’ workflows, proper credential management is crucial to being a quality and accredited health center. The major accreditation agencies (The Joint Commission, AAAASF, AAAHC, and IMQ) maintain strict guidelines when it comes to accreditation, which occurs on-site every several years. As a result, upholding the credential compliancy requirements during the survey is mission critical to the facilities.

So what exactly is on the line if a surgery center has bad credential files? We’ve outlined some costly consequences below that might cause you to take your credential management a bit more seriously.

1. Loss of Accreditation and Medicare Billing

Mismanaged credential files are one of the most common mistakes that facilities make before failing the accreditation survey. If the facility fails their comprehensive review, they are stripped of their deemed and accredited status for meeting the Medicare conditions of participation.

Medicare, the national social insurance program, requires facilities to become accredited by an approved accreditor before they are able to participate. It pressures accreditation agencies to extensively regulate health care providers on their outstanding quality. Many commercial insurers, as well as Medicare, refuse payouts to a facility that fails significant accreditation exams. In other words, unaccredited healthcare facilities cannot provide Medicare-financed services, and these services can total to upwards of $156 billion annually.

Medicare-acknowledged accreditation organizations require at least one year between requesting a survey and receiving that survey, forcing the failing facilities to remain unaccredited for that period. The facilities are financially hurt when they lose patients during that gap time.

2. Risk of Lawsuits

Doctors and facilities face malpractice lawsuits for healthcare fraud when credentialing problems arise and are not adequately addressed. Negligent credentialing lawsuits exist to uphold quality improvement and achievement in the healthcare system.  These lawsuits can cost doctors and facilities hundreds of thousands of dollars, as well as hold the facilities liable for failing to properly select and supervise their medical staff.

The makeup of a poorly managed credential file may include, but is not limited to expired or missing documents and restricted privileges, which disqualifies the healthcare practitioner to treat patients. However, when unqualified physicians practice, the patients are able to file lawsuits against the facility because it may have failed to acknowledge the following:

Restricted or revoked privileges due to a history of bad practice

Lack of board certifications in the physician’s field

Unresolved malpractice suits

Negative peer reviews and references

A negligent credentialing case is exemplified by Darling v. Charleston Community Memorial Hospital in which a physician with faulty credentials performed orthopedic work and costed the patient his leg. Because the facility failed to prohibit the doctor from practicing and did not review his out-of-date procedures, the patient sued the doctor for malpractice and the facility for negligent credentialing.

3. Difficulty in Obtaining a State Licensure

When mismanaged credential files result in failing the accreditation survey, state licensure becomes difficult or impossible to obtain. Similar to accreditation survey groups, public and private agencies inspect and regulate medical facilities to ensure that they comply with the state laws.

The likelihood of passing the inspection is unfavorable when the facility lacks compliant credentials and accreditation and healthcare facilities cannot operate without the appropriate state licensure. It is considered a criminal offense.

These regulations are intensive and stressful. We want to help you avoid them by making sure your documents are in compliance and organized, while saving you time. Find out how Silversheet can help support you in properly managing your physician credential files.