- Economic credentialing - issues and answers
- Comments to the OIG on exclusive credentialing
- HHS releases new guide on the privacy rules
- AMA testifies at Federal Trade Commission Workshop
- AMA files motion to dismiss in NRMP lawsuit
- New guide to medical staff bylaws available
1. Economic credentialing - issues and answers
Definition
Economic Credentialing is the use of economic criteria unrelated to quality of care or professional competence in determining a physician's qualifications for initial or continuing hospital medical staff membership or privileges. (AMA Policy H-230.975)
History
Current economic trends in healthcare have caused hospitals to base credentialing decisions on the level of a physician's referrals to that hospital. Some hospitals have established "conflict of interest" policies or "loyalty oaths" to ensure that physicians will refer their patients to that hospital or risk losing their hospital privileges. Through these policies or "loyalty oaths", some hospitals have refused to grant staff privileges to physicians who own, have financial interests in or have leadership positions with healthcare entities or refer patients to competing healthcare entities.
AMA action
The AMA opposes the use of economic criteria unrelated to patient care to grant
privileges. In December 1999 the AMA asked the Office of Inspector General (OIG)
to issue a fraud alert on this emerging practice. The AMA had several conferences
with the OIG over the ensuing two years regarding the request and in September
2002 submitted another request for a fraud alert. The AMA met with OIG in November
2002 to develop the solicitation for comments published in the Dec. 9, 2002
Federal Register.
In the December notice, the OIG asked the public to comment on certain credentialing practices including:
1. Whether hospital privileges are "remuneration"?
2. What are the implications of a hospital's denial of privileges to a physician who competes with the hospital?
3. Should the exercise of discretion by the hospital affect the analysis under the anti-kickback statute?
4. Can privileges ever be conditioned on referrals, other than minimums necessary for clinical proficiency?
5. What is the effect of credentialing restrictions that apply only to members of a group practice?
The AMA's September 2002 request to the OIG and its response to the solicitation for comments can be accessed online:
Strategies
1. Develop bylaw provisions which clearly articulate membership and privilege criteria, including a provision prohibiting economic credentialing.
Medical staff membership and privileges may be granted, continued, modified, or terminated by the Board only upon recommendation of the medical executive committee for reasons directly related to quality of patient care and other provisions of the medical staff bylaws, according to the procedures set forth in these bylaws. Under no circumstances shall economic criteria unrelated to quality of care be used to determine qualification for initial or continuing medical staff membership or privileges. (AMA Physicians Guide to Medical Staff Organization Bylaws, 2nd Edition)
2. Encourage medical staff involvement in the development of medical staff development plans and strategic planning activities.
3. Encourage medical staff involvement in the development of conflict of interest policies.
4. Encourage membership in AMA and the Organized Medical Staff Section (OMSS) and in order to raise awareness of the many issues affecting medical staffs and to utilize the legislative and advocacy activities. Notify the AMA of economic credentialing practices or policies implemented by hospitals.
5. Establishment of a dispute/conflict resolution process in the medical staff bylaws whereby the medical staff and hospital governing body can discuss and resolve issues that affect the medical staff.
For further information, contact OMSS staff office or the Health Law Division.
2. Comments to the OIG on exclusive credentialing
In response to a request by the AMA, the Office of Inspector General of the Department of Health and Human Services published a notice in the Federal Register seeking comments about physician credentialing practices. The notice asks for public comments in regard to credentialing practices. The OIG poses five specific questions for comment (see below).
The AMA believes that the practice of conditioning a physician's medical staff privileges on an agreement to refer patients only to that hospital is a violation of the anti-kickback law and that privileges are of "value" and often used by hospitals as an inducement to refer patients to that hospital. Whether called loyalty oaths or conflict of interest policies, the effect is the same. These practices have been implemented in many hospitals across the country and negatively impact a physician's prerogative regarding patient care as well as patient choice.
If you would like more information on this issue, please link to:
AMA's draft comments to the OIG (Word, 40KB)
December 9th federal register (PDF, 43KB, requires Adobe® Reader®)
September 2002 AMA letter to the OIG (Word, 34KB)
3. HHS releases new guide to HIPAA privacy regulations
On December 4, the Office for Civil Rights at HHS released "Standards for Privacy of Individually Identifiable Health Information" (the "Guidance"). To review a brief description of the Guidance and a one page Highlights visit the AMA's HIPAA Web page.
4. AMA testifies at Federal Trade Commission Workshop
The AMA participated in a recent workshop sponsored by the Federal Trade Commission focusing on health care antitrust issues. The AMA was invited to participate in two panels - the first on physician integration and FTC enforcement policies and the other on concerns surrounding provider/payor issues.
Catherine Hansen of California Medical Association did a great job presenting the physician issues paper on behalf of the AMA. In this testimony, the AMA asks the FTC to take a "fresh look" at its attitude towards non-exclusive, non-integrated physician networks. Dr. Palmisano presented testimony discussing the physician's perspective on health plan market power and abuses which was based in large part on the payor market study developed by Private Sector Advocacy. Click below to read the written papers that were submitted in conjunction with our oral testimony.
On integration, physician joint contracting, and quality: Taking a fresh look at some "settled" questions (Word, 76KB)
5. AMA files motion to dismiss in NRMP lawsuit
On Sept. 9, the AMA filed a motion to dismiss antitrust claims against it related to operation of the FREIDA database in the National Resident Matching Program lawsuit (NRMP). Specifically, the AMA motion states that allegations in the complaint are insufficient, as a matter of law, to establish violations of the federal antitrust laws. The AMA filed an additional motion seeking dismissal of claims against it solely by reason of its status as a "governing sponsor" of the NRMP and as a sponsoring organization of the Accreditation Council for Graduate Medical Education. The motions were filed with Judge Paul Friedman in the US District Court for the District of Columbia. He will establish a timetable for future proceedings. More information will be provided as it becomes available. Learn about the litigation and the AMA's position.
Full text of the motion (PDF, 1MB)
6. New guide to medical staff bylaws available
The 3rd edition of the Physicians Guide to Medical Staff Organization Bylaws is now available. The 2nd edition of the Physicians Guide to Medical Staff Organization Bylaws is now available at online. This guide discusses the changes taking place in today's health care environment and the emerging issues facing the organized medical staff. As the structure under which the medical staff provides care in the hospital, bylaws that are well designed and well drafted help the medical staff respond to these changes while continuing to meet its responsibility for providing quality care to patients. This Guide discusses how to review, write or amend bylaws and provides model bylaw language. Print copies of the Guide will be available in mid-October. For ordering information, call toll free (800) 621-8335. Mention product number OP424502.
Content provided by: Office of General Counsel