Medical Staff Credentialing & Peer Review in Illinois
Medical Staff Credentialing
Hospitals and many health care entities are required by law to evaluate the competency of physicians providing services to patients at their facilities. Credentialing is the process by which hospitals and health care entities verify and evaluate the qualifications of physicians to ensure they possess the necessary qualifications. Physicians can apply for both medical staff membership and clinical privileges at hospital and certain health care entities. A clinical privilege is a right granted by a hospital or a health care entity to a physician that allows the physician to perform certain procedures or operations, or to admit patients at the hospital. Hospitals and health care entities verify physician qualifications for medical staff membership and clinical privileges through the credentialing process, which includes the collection, verification and evaluation of information and data relevant to the physician’s education, training and professional experience.
Physicians may be denied membership or privileges because of something in their background (e.g. prior disciplinary action, professional license discipline, criminal history, issues with education/training, and medical malpractice judgments or settlements). In addition, physicians may be denied privileges when they fail to accurately answer questions on a credentialing application or fail to disclose issues in their background. Sometimes, the credentialing process is used to deny a physician membership or privileges at a hospital or health care entity for improper purposes. The denial of medical staff membership or privileges may be reported to the National Practitioner Data Bank (NPDB). Consequently, it is important that you immediately contact a health care attorney for assistance when you learn of problems with your credentialing or privileging application at an Illinois hospital or health care entity.
The attorneys at Goldberg Law Group regularly advise and represent physicians and other practitioners who have been denied medical staff membership and/or clinical privileges. If there is something in your background which you think needs to be disclosed and/or may result in your credentialing application being denied, you should seek immediate legal advice from an experienced health care attorney. Our team of attorneys will evaluate the information and help you explain the issue to the hospital in the best light.
Medical Staff Peer Review
In general, the peer review process is instituted when a physician’s performance or behavior is called into question. Peer review can result in disciplinary action (i.e. the suspension, restriction, termination, revocation or non-renewal of a physician’s medical staff membership and clinical privileges). Disciplinary action, in turn, results in a cascade of legal consequences that can be devastating to a physician’s medical practice and reputation.
A physician facing the prospect of a peer review should seek help from an experienced health care attorney, who is familiar with medical staff peer review, as soon as the process begins. An understanding of the peer review process, and its consequences, is important for any physician faced with the prospect of peer review. The sooner you seek legal advice, the better you will be able to protect yourself from potentially devastating consequences.
Medical staff peer review is subject to certain protections and requirements set forth in Federal and Illinois State laws, which should be reflected in the medical staff bylaws and credentialing policies of the institution. Sometimes the bylaws do not match the requirements of Illinois State and/or Federal laws. Sometimes the institution will not follow their bylaws altogether. It is essential that an affected physician hire an experienced health care attorney to guide them through the peer review process and ensure that they are being afforded due process.
The consequences of peer review go far beyond whether a physician will retain his ability to work at a particular hospital or health care entity. Many peer review actions result in a report to the NPDB, a national clearinghouse of information regarding physician misconduct. An NPDB report stating that a physician was subject to discipline by peers will be reported to the Illinois Department of Financial and Professional Regulation and can be the basis for an investigation and disciplinary action by the Board. The NPDB report will also be available to other hospitals and health care entities, federal agencies, state agencies administering health care programs, health plans, private accreditation organizations, peer review organizations and private accreditation organizations.
Sometimes problematic clinical or behavioral performance by a physician will be addressed informally by a hospital or health care entity through administration or a departmental chair. A physician may be approached with an alleged competence or conduct issue and offered a warning or counseling, or will be asked to complete a performance improvement plan or some type of voluntary remediation. When considering whether to accept such informal action, the biggest concern is whether it is reportable to the NPDB. An experienced health care attorney’s counsel can be invaluable in helping to guide the process to the client’s advantage. When informal disposition is not available, the matter will often proceed to the formal investigation and fair hearing stage.
An investigation may be initiated by another physician, a medical staff department, or the medical staff’s Medical Executive Committee (“MEC”) after a poor patient outcome, a report of disruptive behavior, or a complaint of physician impairment. Sometimes the reason for the investigation is motivated by something other than medical care or behavior.
Depending on the severity of the allegations, the hospital or health care entity may decide to summarily suspend the physician’s privileges during the investigation. Under Illinois law, a hospital may only summarily suspend a medical staff member’s clinical privileges if there is actual documentation or other reliable information of an immediate danger to patients or the public. A suspension of privileges that stays in effect for more than thirty days is reportable to the NPDB. But, the hospital must give the physician an expedited hearing within 15 days of the suspension.
At the beginning of any investigation, the hospital should notify the physician in writing of the allegations. During the investigation, the physician’s ability to actively defend against the allegations is limited, but he or she should be offered an opportunity to respond to the allegations, verbally and/or in writing.
When the investigation is concluded, the MEC, or similar committee responsible for governing the medical staff, will make a recommendation. The MEC may recommend that the physician’s clinical privileges be suspended, restricted, terminated, or revoked. If so, the MEC must timely notify the physician in writing of the reasons for its recommendation and inform the physician of his or her right to request a hearing.
If the physician decides to resign his or her privileges during investigation, it will result in a NPDB report.
While peer review is designed to promote and improve quality of care for patients, it can be a contentious process, and is sometimes used for an improper purpose. The results of a peer review can severely and adversely affect a physician’s ability to practice medicine. It is important for a physician involved in the peer review process to retain experienced legal counsel with knowledge of Illinois State and Federal peer review laws. The attorneys at Goldberg Law Group routinely assist physicians in their interactions with hospital and health care entities during peer review and ensure that the hospital conducts the process in accordance with Illinois State and Federal laws and the medical staff bylaws.
Contact Jenna E. Milaeger at 312-930-5600 for more information and to schedule a free initial consultation.
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Practice Areas in Illinois
Medicare & Medicaid Audits
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Our attorneys are vigorous advocates for physicians in medical staff hearings and appeals. We work hard to protect and preserve the rights of Illinois and Arizona physicians under the medical staff bylaws and state and federal laws and defend adverse actions that threaten your membership and privileges.
Medical Staff Credentialing & Peer Review
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