In Schelling v. Humphrey (2009), the Supreme Court of Ohio ruled that a plaintiff can bring a negligent credentialing claim against a hospital without filing a malpractice claim against an individual practitioner.
However, in Plaisance et al., v. Our Lady of Lourdes Regional Medical Center, Inc., et al. (2010), an appeals court in Louisiana ruled that the plaintiffs had to establish a malpractice claim before they could establish that the medical staff knew about the pattern of alleged malpractice behavior and went ahead with its credentialing, thus negligently credentialing the practitioner.
These rulings show that in some states it’s more difficult to prove a negligent credentialing claim if a malpractice claim has to be established first.
The goal for MSPs remains the same: process applications with due diligence to avoid negligent credentialing or even the appearance of it. Ultimately credentialing best practices will help keep the medical staff out of the court room, for malpractice or negligent credentialing cases.
The largest Medicare fraud operation conducted by a single group was recently taken down, the Department of Justice announced earlier this week. The accused individuals allegedly stole the identities of physicians and Medicare beneficiaries to set up shadow clinics to bill for unnecessary services and/or procedures that were never performed.
Here are some of the statistics from the case:
- 73 defendants were charged with various healthcare fraud-related crimes
- $163 million in fraudulent billing was sent to Medicare
- 118 alleged shadow clinics submitted Medicare charges
- 25 states housed the shadow clinics
“The [accused] perpetrated a large-scale, nationwide Medicare scam that fraudulently billed Medicare for more than $100 million of unnecessary medical treatments using a series of phantom clinics,” said Kevin Perkins, FBI Assistant Director of the Criminal Investigative Division, in a press release. “We want to restore the confidence in the nation’s health care system and assure practitioners we will not stand by and let their identities be used for criminal gain.”
This case highlights the important work MSPs do in verifying Medicare and Medicaid sanctions to ensure the proper sanctions are rendered and to stop identity fraud in its tracks.
When medical staffs face a legal problem, they have a choice as to whether they use the hospital’s legal counsel or secure their own counsel. The fact that there is a choice may seem obvious, however, in most instances this may be a hidden choice as medical staff may be likely to use whatever lawyer they used in the past, rather than exploring a new option. If the legal problem the medical staff is facing puts the medical staff at odds with the hospital, the medical staff may be more likely to pursue their own lawyer. Nevertheless it’s important for medical staffs to understand the differences between hospital lawyers and medical staff lawyers and which agent to call.
“The medical staff leadership should be able to get advice from a knowledgeable lawyer that they trust,” says Constance Baker, Esq., partner at Venable, LLP, in Baltimore, who represents hospitals and medical staffs. “I don’t think they generally need separate legal counsel except for these unusual circumstances where the culture may have been such that the medical staff simply cannot trust the hospital leadership or there have been historical reasons why the relationship is not going to work out with the hospital counsel and medical staff.”
One of the reasons why it may be easy for lawyers to play on both teams at once is because often the hospital and medical staff have closely aligned interests, from meeting accreditation requirements to serving the community.
“Any advice that any well-trained, seasoned, experienced hospital attorney can provide really benefits both sides—and in many senses there aren’t two sides, they really are the same side,” says Michael R. Callahan, Esq., partner with the healthcare practice group of Chicago-based Katten Muchin Rosenman, LLP, who represents hospitals and medical staffs.
Yet, there’s another school of thought that suggests medical staffs need their own lawyers who can solve problems solely from the medical staff’s point of view.
“[Hospital lawyers] represent the hospital so when they are explaining the impact of the due process procedures, how you request a hearing, and what the physician’s rights are, they can explain them without necessarily saying, ‘and if you’re the doctor at the other end of it, it’s a bad idea for you,’” says Michael Cassidy, Esq., of Tucker Arensberg, PC, in Pittsburgh, who represents medical staffs and practitioners. “They don’t go that last step because they’re not supposed to.”
When MSPs conduct criminal background checks on practitioners or search for them on the OIG’s List of Excluded Individuals/Entities, chances are the results will reveal an honest application. However, that doesn’t mean practitioners aren’t committing insurance fraud.
Case in point: Sushil Sheth, MD, cardiologist from Chicago who was recently found guilty of stealing $13 million from Medicare and 30 other insurance companies over a five year period. Law officials say Sheth held privileges at three hospitals where he obtained patient information that he used for false billing purposes.
Click here to read more about the case which highlights the importance of conducting background checks.
For a while now we’ve been following the story of Anne Mitchell, RN and Vicki Galle, RN who reported a physician to the Texas Medical Board. It seemed that the final chapter was written in February when Mitchell received a not guilty verdict from the jury. Galle’s case had been dropped earlier.
However, the latest detail of the case emerged this week with the announcement that the nurses will share a $750,000 payment from Winkler County, TX where the original charges were filed.
Take the poll below to see how your medical staff compairs to others.
Carey Ann Ryan, a nurse-midwife working in Iowa, recently agreed to pay a $1,000 fine to the state and enroll in an ethics education program in part because she did not tell a high risk patient that she did not have hospital admitting privileges, according to a July 22 article on DesMoinesRegister.com.
The patient in question eventually switched healthcare providers before her delivery and delivered in a hospital four weeks before her due date.
The case raises interesting questions about what information practitioners—hospital based or otherwise—should disclose to their patients.
Other issues that practitioners disclose to their patients may include if they accept Medicaid payments and if they have ties to pharmaceutical companies.
What information do your medical staff members disclose to patients? Share your experiences in the comment boxes below.
Physicians support the idea of reporting their impaired peers to the appropriate authorities, but won’t always report when faced with those situations in real life, according to a study in the Journal of the American Medical Association (JAMA).
Approximately 1,900 physicians participated in the study, “Physicians’ Perceptions, Preparedness for Reporting, and Experiences Related to Impaired and Incompetent Colleagues.”
The findings revealed that 64% of respondents, “agreed with the professional commitment to report physicians who are significantly impaired or otherwise incompetent to practice,” according to the study.
Additionally, 17% of respondents had direct, personal knowledge of an impaired practitioner, but only 67% of this group reported the impaired practitioner.
Which groups of physicians were mostly likely to report, according to the study? Those working in a hospital setting or a medical school were most likely to report.
The study found that physicians that don’t report do so because they think someone else will report the impaired practitioners.
The American Board of Internal Medicine (ABIM) claims that about 140 practitioners cheated on certification exams, according to a June 9 Wall Street Journal article. (http://online.wsj.com/article/SB10001424052748704256604575294712195930970.html). The practitioners allegedly purchased test questions from a test-prep company, which violates the ABIM’s test policy signed by test takers.
However, Christine Cassel, M.D., president and chief executive of the ABIM, is quick to point out that most test takers are honest and take the certification exam in good faith.
Click here to learn more about the case, and read “ABIM Sanctions Physicians for Ethical Violations,” on the ABIM’s website. (http://www.abim.org/news/ABIM-sanctions-physicians-for-ethical-violations.aspx)
It can be challenging for medical staffs to address issues that don’t have clear, black and white answers. For example, how would your medical staff respond to a practitioner who has excellent clinical skills but exhibits disruptive behavior? What if your medical staff had worked hard to recruit a practitioner, only to find out shortly thereafter that he had relapsed into chemical dependency? Obviously there are some clear regulatory standards that must be followed in these instances, but there are also ethical issues and concerns that each medical staff must address individually.
Take our poll below and find out how your organization compares with your peers’ organizations.