As we reach the end of the year, a multitude of various forms inevitably end up in health care providers’ offices. Most notably, the license renewals, privilege applications, and malpractice coverage renewals that all pose somewhat similar, yet subtly different, questions. Many health care providers make the mistake of delegating these forms to office staff. While each application asks for similar information, there are nuances to each form and the failure to accurately complete any of these applications can have long-standing consequences to a health care provider. Below are some of the common queries from state agencies, health care facilities, and insurance carriers and some explanations as to the inquiry and common pitfalls for providers.
• Pending Investigations and Adverse Actions. One of the most common questions is whether the provider has been subject to any charges or complaints (including all lawsuits) or had any disciplinary action or adverse actions taken against a license, certificate, registration, or privilege. The latter is quite easy as you should know if there was disciplinary or adverse action taken against you. However, the tricker question is if you have been subject to charges or complaints. For instance, patients often submit a complaint against a provider that triggers an investigation. This is technically a complaint, but most are closed without any formal disciplinary proceedings or actions. Yet, many providers fail to disclose such complaints. Likewise, if an indemnity payment is made arising out of a malpractice action, reporting is likely required even if the case did not go to trial. The provider needs to carefully read the question and whether a response and explanation is necessary. If a doubt, it is always better to disclose and explain rather than to roll the dice on non-disclosure.
Almost every license, registration or certification requires a health care provider notify them about any disciplinary or adverse actions. Some even require the notification sooner than on your renewal form and care must be taken to know the specific notice requirements. Failure to disclose a disciplinary or adverse action to a licensing entity is one of the quickest and easiest ways to ensure an investigation. Further, for those providers licensed in multiple states, if an adverse action is taken in one state, the state board will typically notify other states of that adverse action. A physician’s failure to notify all states of an adverse action frequently is seen as an honesty issue, resulting not only in the other states adopting the initial action taken by the original state, but also expanding the investigation to question the character of the defending physician.
Similarly, an insurance company will want to be aware of any adverse action as it results in the decision to insure and at what rates. A failure to accurately report could result in the insurance carrier later moving to rescind your coverage claiming it never would have insured you had it known the material fact about a disciplinary or adverse action. Even further, this failure to disclose could create issues with both public and private payers. For many providers, Medicare and Medicaid patients are often a significant portion of practices patient population. A physician’s loss of that privilege can have adverse impact to participate in private insurance plans, as well as on his or her malpractice coverage.
• Collaborative Practice Agreements. Health care is moving towards increased use of mid-level providers and many renewal forms want to know about collaborative practice agreements. More specifically, they want to know how many mid-level practitioners the physician is acting as the collaborative physician, as most states have a limit. They may also want to make sure you are supervising a mid-level provider in your same area of practice and what you do to ensure compliance with your state statutes and regulations. Physician agreements and employment of physician extenders can significantly change from year to year. In Missouri, collaborative practice agreements require a physician to review a certain percentage of charting each month from that nurse practitioner. Likewise, malpractice insurance companies want to confirm whether physician extenders are providing treatment under the physician’s name for coverage and risk assessment purposes.
• Privilege and Specialty Certifications. Most physicians have privileges to practice at health care facilities and are further certified by some accreditation entity. However, as time progresses, certain certifications are either added or dropped. Health care facilities frequently look at those certifications to determine which privileges to extend to a health care provider and ensure the health care provider is providing treatment consistent with his training and certifications. In our experience, health care facility forms are the most varied forms and require a specific attention to detail. These forms are typically more open-ended in their questions with no limitation on time or scope. For instance, some hospital privileging forms ask if you have ever been subject to a complaint, investigation, or disciplinary proceeding by any entity or agency. Some ask if you have ever experienced a condition or impairment that affects your ability to practice medicine. Further, insurance companies, like other facilities, want to ensure that physicians are providing treatment consistent with their training and experience.
Lashly & Baer’s general recommendations in completing license renewal, privileging, or insurance applications is to first check the dates. While we may frequently have a general idea when certain events occur regarding licensing privilege applications, or that privileging renewals occur every two years, most license renewals and malpractice applications typically happen on an annual basis. Be sure responses are being made in respect to the timeframe asked by the respective entity. The second general recommendation is to review the applications yourself. While time-consuming, do not rely solely upon office staff to ensure accurate representation. In particular, if you’re practicing in multiple states or hospital systems, be sure that all privileges and licensures are included in applications. If the application is submitted in error, the adverse action— denial of privileges, investigation of licensing – will not be brought against staff, but the practitioner.
If at any time you have questions, do not hesitate to reach out to Jeffrey Atkinson or Michael Barth or your Lashly & Baer attorney specializing in health care law. Taking the time to accurately complete these renewal documents on the front end can often prevent significant problems later that can result in further explanations, investigations, legal expenses, and even the ability to practice your trade.