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Economic Credentialing

A Valuable Source of Revenue and Protection for your Hospital
As medical costs have increased and reimbursement has declined or been stagnant, both hospitals and physicians have come under increasing financial pressure. Insurance companies are progressively using various methods to rate physicians based upon quality and cost.

“A board-certified cardiologist or internist or pediatrician used to be like the Pope: The physician passed a test just once, early on, and carried the “board-certified” designation for life, no re-qualification or retesting required. (Today, however), board-certified physicians who are held to a stricter standard must complete a battery of requirements and then pass a retest to hold onto that certificate.”

What we’re looking for is a higher-performing physician
Matt Schuller, Dir. Clinical Affairs Blue Cross & Blue Shield Assn.

"We want to have (a) continuing education program that maintains certification according to the highest standard of practice and clinical care, and (is) updated to reflect the ever changing science of medicine."
Bala Pai, MD, Medical Director, Health Alliance Plan

These requirements are referred to as Maintenance of Certification (MOC). Many health plans are adopting MOC with a view to create more cost-effective care.

There has been some resistance to the MOC process. Some doctors typically said the process takes too much time, costs too much, and isn’t needed for their employment.

“Truth be known, people will complain about it beforehand because it seems like a lot of work,” says ABIM’s Christine Cassel, MD. “We do get complaints, mostly from people who haven’t done maintenance of certification yet.” Once they do, they embrace it.”

NOTE: “Ninety-one percent (91%) of all active board-certified family physicians are participating. However, physicians who work in poorer neighborhoods” (including those in rural areas), “who are US-born or foreign-born international medical graduates, or who are solo practitioners are more likely to have missed initial MOC.

The connection between practicing in undeserved areas and lapsed board certification, however, (needs) more research (to find) the causes of (this disparity) in participation.”

Health plan insurers are increasingly seeing the value in rewarding physicians for participating in their maintenance-of-certification programs.

The financial rewards to the participants can be substantial. However, failure to become properly credentialed can have catastrophic consequences for hospitals, physicians and their patients.

"Aligning the incentives with maintenance of certification…can solve two problems: (Physicians) will get paid more, and…(then) they can submit (these MOC documents) to ABIM and get credit for MOC requirements."                                                                                                                  Richard Snyder, MD.

"Depending on final score, the physician can see an increase in his or her fee schedule that…probably averages 4 to 6 percent (4%-6%) on their Evaluation and Management (E&M) codes."
                                                                                                                         Rome Walker, MD, of WellPoint

“It can be a costly error for smaller organizations to assume that only large medical institutions with ample resources are expected to scrutinize practitioners’ credentials.”

There has been a tremendous increase in the number of negligent credentialing claims being filed in conjunction with traditional medical malpractice claims.

With physicians carrying less malpractice insurance than in the past, hospitals are targeted as having "deeper pockets."

Case #1: Frigo v. Silver Cross Hospital & Medical Center

(2007) A negligent credentialing case, an Illinois appellate court upheld a $7.7 million jury verdict. The plaintiff sued the defendant hospital based upon its appointment of a podiatrist to the medical staff who failed to meet the hospital’s established criteria for receiving Level II surgical privileges.

(Outcome: Patient’s foot became gangrenous, requiring amputation.)

Case #2: Columbia/JFK Medical Center v. Sangounchitte


(2008), a Florida appellate court, in, upheld an $8.5 million dollar jury verdict against a medical center which allowed a physician to have hospital medical staff privileges to perform spinal surgery, despite the fact that he demonstrated “marginal proven competence”.
                                 (Outcome: Metal rods inserted in the patient’s spine migrated upward into the brain, causing brain damage.)

It is disturbingly easy for plaintiffs' attorneys to simply tack such a claim on every lawsuit if there is the slightest hint of something off in the credentialing process (and it is not hard to find something).

“Organizations that approve privileges without fully verifying an applicant’s qualifications and proficiency risk lawsuits alleging negligent credentialing practices.”

Granted, there can be a significant amount of paperwork to be managed in order to get health care professionals credentialed and linked with insurance providers; and since this process can take as much as a year or more to complete, involving multiple mailings of multiple documents to multiple entities, some small rural and critical access hospitals do not have enough staff or enough experience to cope with this tedious, time consuming, process.

Recognizing that some facilities may need assistance with the credentialing process, Medical Recovery Services has made an addition to their service portfolio: Medical Credentialing. A member of our staff, with well over twenty years’ experience in the health care field and with specific experience in credentialing, has been assigned to work on medical credentialing with our clients. As always, affordability is a principal concern for us. Our mission statement states:

"Medical Recovery Services is committed to enhancing the financial viability of small community and critical access hospitals by providing a full range of services at exceptionally affordable rates. We sincerely believe the benefits of our services should outweigh the cost and be designed to maximize the positive financial impact for each hospital’s specific circumstances."


For more information, contact Medical Recovery Services

(816) 229-4887

Medical Recovery Services is a full-service revenue cycle company assisting

hospitals and surgical centers in achieving their full earning potential since 2004.

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