Medical personnel face numerous challenges in maintaining their professional standing, from securing proper licensing to navigating credentialing disputes involving staff privileges and peer review. While these processes are in place to ensure quality patient care and to uphold professional standards, they can also become contentious and complex for physicians to navigate on their own. Whether addressing licensing board investigations, defending against unfair peer reviews, or resolving issues with staff privileges, healthcare providers can not only struggle to navigate maintaining credentials but can even find their careers and reputations on the line. Experienced healthcare law lawyers who understand the intricacies of these challenges can provide important guidance to physicians that is both proactive and reactive.
Board Certification
Being certified by a medical specialty board signifies to other medical professionals that you are an expert in your field and assures patients that they can expect high-quality care. However, achieving board certification is a lengthy and sometimes challenging process. To attain certification, physicians must demonstrate good professional standing, complete the education and training necessary to meet the core competencies expected by the specialty board, and show that their knowledge, judgment, and skills meet the established standards. Lack of board certification in a specialty can create significant obstacles for healthcare providers, including difficulties with getting physician employment or credentialing at health plans and hospitals. Additionally, losing board certification may result in mandatory reporting to the National Practitioner Data Bank (NPDB), further complicating a provider’s professional prospects.
Enrollment
An increasing number of providers are experiencing revocations of their Medicare billing privileges. While the Centers for Medicare & Medicaid Services (CMS) emphasizes that its revocation authority is designed to safeguard the Medicare program and its beneficiaries from dishonest or non-compliant providers, it also imposes strict accountability on all participants to adhere to the complex Medicare enrollment laws, regulations, and policies. Providers facing challenges with Medicare enrollment or dealing with the revocation of their Medicare billing privileges should consult with an attorney who has experience managing the enrollment process or appealing revocation decisions.
Medical Credentialing
Medical credentialing plays a pivotal role in maintaining the quality and reliability of healthcare. This involves a thorough evaluation of a provider’s qualifications, such as their education, training, residency, licensure, and certifications. The medical credentialing process ensures that healthcare providers meet the necessary standards to deliver safe and effective care to patients. Hospitals, group practices, and networks like HMOs and PPOs also use medical credentialing to determine whether a provider is suitable for affiliation, thereby safeguarding the integrity of their organizations and the welfare of their patients.
While medical credentialing is crucial, the process can present significant challenges for healthcare providers. Many individuals encounter difficulties when seeking credentialing for the first time or maintaining their credentials over time. These challenges can stem from administrative errors, disputes during peer review, or other complex issues.
Failing to obtain or losing credentials can have far-reaching consequences. Providers may face termination of staff privileges, exclusion from provider networks, or mandatory reporting to state and national data banks, such as the National Practitioner Data Bank (NPDB). Such reports can tarnish a provider’s professional reputation, making it harder to secure future opportunities. These repercussions not only threaten a provider’s ability to practice medicine but can also jeopardize their income, disrupt patient care, and undermine their standing within the healthcare community.
Peer Review
Peer review is the process by which physicians evaluate the performance, qualifications, and quality of care provided by their colleagues to ensure adherence to professional standards and patient safety. If a hospital participates in Medicaid and Medicare programs, establishing a peer review committee is a mandatory requirement.
When conducted appropriately, the peer review process serves as a safeguard for patients, ensuring they receive high-quality care, preventing medical errors, and reducing the risk of injury or death. However, not all peer review is conducted to attain these ideals. The peer review process can be misused for unjust purposes (called “sham peer review”), such as retaliating against a physician or eliminating competition. Besides undermining the integrity of the important process of peer review, this misuse can result in devastating consequences for the targeted physician’s career, such as a loss of privileges or damage to a physician’s professional reputation.
Staff Privileges
Staff privileges are a critical aspect of a physician’s ability to practice medicine within a hospital or healthcare facility. These privileges, granted by a facility’s credentialing committee, allow medical professionals to admit patients, perform procedures, and provide care within the institution. For many physicians, staff privileges are not only a professional necessity but also a cornerstone of their practice, enabling them to access essential resources and serve their patients effectively.
The process of obtaining staff privileges involves rigorous evaluation, including a review of a physician’s education, training, licensure, certifications, and prior practice history. This ensures that only qualified individuals are granted the authority to practice within the facility, safeguarding patient care and maintaining institutional standards. However, obtaining or maintaining staff privileges is not always straightforward. Physicians may face challenges due to credentialing issues, peer review disputes, or allegations of substandard care.
Losing or having staff privileges restricted can have far-reaching consequences. Such actions are often reportable to the NPDB, which may tarnish a physician’s professional record and make it difficult to secure privileges at other facilities. Additionally, losing staff privileges can disrupt a physician’s ability to provide continuity of care, leading to a loss of referrals, patients, and income.
Contact An Experienced Medical Credentialing Attorney
Navigating the complexities of maintaining professional standing in the healthcare field requires diligence, expertise, and the right support. When faced with challenges such as credentialing disputes, licensing investigations, or unfair peer reviews, physicians should not have to face these battles alone. An experienced medical credentialing attorney can offer proactive strategies to avoid issues and strong advocacy when problems arise. They can help you to safeguard your credentials–the key to your ability to practice–so that you can focus on patient care. Contact our firm today to learn more.