Clinic Credentialing And Privileging FAQs
This Nurse Resigned In May 2020
GAO found that Veterans Health Administration (VHA) facilities responded in various ways to adverse-action information from the National Practitioner Data Bank (NPDB) for the 57 providers reviewed, and in some cases overlooked or were not aware of adverse action.
In some cases, providers had administrative or other nondisqualifying adverse actions reported in the NPDB, but VHA facilities determined they could be hired. For example, VHA hired a physician who had surrendered his physical-therapy license for not completing physical-therapy continuing education. Although his license surrender resulted in an adverse action in NPDB, VHA determined that there were no concerns about the provider's ability to perform as a physician.
VHA facilities disciplined or removed providers when they learned about adverse actions reported in NPDB. In addition, after GAO raised questions about certain providers' eligibility, based on GAO's examination of adverse-action information, VHA facilities removed five providers that it determined did not meet licensure requirements.
In some instances, VHA facilities overlooked or were unaware of the disqualifying adverse-action information in NPDB. In these cases, VHA facilities inappropriately hired providers, but some providers were no longer working at VHA at the time of GAO's review. For example, VHA officials told GAO that in one case, they inadvertently overlooked a disqualifying adverse action and hired a nurse whose license had been revoked for patient neglect. This nurse resigned in May 2017.
VHA facilities did not consistently adhere to policies regarding providers with adverse actions. Among other issues, GAO found that some facility officials were not aware of VHA employment policies. Specifically, GAO found that officials in at least five facilities who were involved in verifying providers' credentials and hiring them were unaware of the policy regarding hiring a provider whose license has been revoked or surrendered for professional misconduct or incompetence, or for providing substandard care. As a result, these five VHA facilities hired or retained some providers who were ineligible. VHA provides mandatory onetime training for certain VHA staff, but not for staff responsible for credentialing. The absence of periodic mandatory training may result in facility officials who are involved in credentialing and hiring not understanding the policies and hiring potentially ineligible providers.
VHA officials described steps they have taken to better ensure that providers meet licensure requirements. For example, VHA completed a onetime review of all licensed providers beginning in December 2017 and removed 11 providers who did not meet the licensure requirements as a result of this review. VHA officials said these types of reviews are not routinely conducted, and noted the review was labor intensive. Without periodically reviewing those providers who have an adverse action reported in NPDB, VHA may be missing an opportunity to better ensure that facilities do not hire or retain providers who do not meet the licensure requirements.
Why GAO Did This Study
VHA provides health services to almost 9 million veterans at medical facilities nationwide. Through the credentialing process, VHA facilities determine whether providers have the appropriate professional qualifications to provide care. The NPDB is one information source VHA uses to determine whether providers have been disciplined by a state licensing board or a health-care facility. Such discipline results in “adverse actions,” that may disqualify providers from practicing at VHA.
GAO was asked to review how allegations of provider insurance credentialing services misconduct are resolved. GAO examined (1) how officials at VHA facilities responded to adverse-action information received through NPDB, (2) how VHA facilities adhered to polices regarding providers with adverse actions, and (3) steps VHA has recently taken to ensure that providers meet licensure requirements. GAO analyzed a nonprobability sample of 57 health-care providers-including physicians, nurses, and dentists-working at VHA as of September 2016 who had an NPDB record. GAO considered factors such as the seriousness of the offense reported to NPDB. GAO reviewed state licensing-board documents. GAO also examined VHA policies, and interviewed VHA officials.
What GAO Recommends
GAO is making seven recommendations, including that VHA ensure that facility officials responsible for credentialing and hiring receive periodic mandatory training, and periodically review providers who have an adverse action reported in NPDB. The agency concurred with GAO's recommendations.
