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Reappointment Time

10 rules to obey By Philip Dray, MD, and Charlene Luchsinger, CPMSM, CPCS

It’s that time again. You must reapply for medical staff privileges every two years regardless of tenure or how priceless you are to your hospital—it’s the law. To reapply, you must use the state’s Health Care Professionals Recredentialing and Business Data Gathering Form, which includes updates that have occurred in the last four years. The form is divided into two chapters: Chapter A contains practice and professional information; Chapter B has business information. To avoid getting tangled in an administrative quagmire, you must follow the rules listed here.

1. Fill out the document yourself. If your administrator fills it out for you, read it line-by-line to make sure it reflects reality and what is known about you. When you sign the application, you affirm that “falsification or omission of information may be grounds for rejection or termination…” Honest mistakes and typographical errors do occur but anything that suggests you are concealing information pertinent to the decision of the Credentials Committee (CC) reflects badly on your professionalism.

2. Do not misrepresent yourself in any fashion. If you are board-certified, that’s great. If you have lost your certification or never had it, state the facts.

3. Include all your hospital appointments and professional work history. Each one will be verified by the Medical Staff Office (MSO) or a Credentials Verification Office (CVO). The MSO/CVO will query each employer to confirm your good standing. Omission of an organization is a red flag.

4. The Adverse and Other Actions section generally causes the most consternation for applicants. These questions are worded awkwardly and generally place applicants on the defensive. A common mistake is to answer “no” to a question that technically requires a “yes” such as voluntary medical staff resignation. Concealing any information in this category raises a professionalism red flag.

5. The question about Professional Liability Action is confusing. Reveal everything that ever happened to you, even if it means telling a story that is 25 years old—again. Omitting old historic information may not be an issue, however. To clarify, you may call the MSO/CVO and ask if they wish to have only updates or the entire history.

6. The MSO/CVO may consider new events (in the last four years) relevant if they fall under the sections on Liability Insurance, Criminal Actions, Medical Conditions, Chemical Substances or Alcohol Abuse, and Investments. Some organizations only want information since your last reappointment. A “yes” answer is not a death sentence but omitting a “yes” will indict your credibility and professionalism. Concealing information in these categories will make you subject to immediate summary suspension and dismissal.

7. When you fill out one of the explanation forms (Forms A through E), complete it so the reader will gain additional information and a clear understanding of the event or circumstance. You are writing it, so explain it the way you want it to be viewed using the facts and truth. Full disclosure is a positive and proactive approach.

8. Remember that the MSO/CVO will verify your information with the source and the AMA for the following: all past and current state licenses, DEA controlled substance license, hospital appointments, work history, alleged malpractice history, insurance, medical school and residency training programs—completed or not, fellowship, specialty boards, National Practitioner Data Bank, state licensing boards, and state Office of the Inspector General (Criminal Actions).

9. Ask for privileges that you actually have the credentials to perform and have met the criteria to perform. Performance and quality data can and will be used to support your request. Denial of privileges or restrictions placed upon a privilege can be a reason for a Data Bank report. Relinquishing a privilege due to changing practice patterns unrelated to disciplinary action is a common benign event and not reported to the Data Bank.

10. The risk of a failed reappointment due to an honest error is tiny. But concealing significant information will be unfavorably looked upon and cause either a delay or rejection of your appointment. A Data Bank report may be filed with a failed appointment and at a minimum will need to be revealed and explained on all future applications.

A supplementary hospital application, updated CV, as well as satisfactory CME are often required. Some applications are created online but they contain essentially the same information as the state form. You must take this task as seriously as any medical procedure on a patient. Welcome back aboard.

Philip Dray, MD, is the past chairman of the Credentials Committee at Stroger Hospital. Charlene Luchsinger is the system director of credentialing at Cook County Health and Hospitals System.

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