A Brief History:
In 1986, Senator Ron Wyden of Oregon introduced and Congress passed the healthcare Quality Improvement Act (HCQIA). Prior to this, there was no national system in place by which to track physicians who relocated to avoid claims of malpractice or unethical behavior, nor to verify where they had been and what kind of medicine they were qualified to practice.
The HCQIA act now allows a physician to participate in the peer review process with immunity as long as it is done in good faith. This act created the National Practitioner Data Bank (NPDB) to ensure the reporting of malpractice in which a physician is held liable for damages. This act covers only physicians and dentists.
In 1996 the Healthcare Integrity and Protection Data Bank (HIPDB) was created to collect information about federal and state criminal convictions, civil judgements, licensure denials, exclusions from health plans, or clinical privileges and other adverse actions on healthcare providers, suppliers and practitioners. It became operational in November 1999.
The Credentialing Process:
Practitioners fill out and submit the Oregon Practitioners Credentialing Application and must include a valid Oregon license, malpractice insurance facesheet, Drug Enforcement Administration (DEA) certificate and other required attachments. If a physician is board certified, IPS does not need to verify education unless credentialing to Joint Commission Standards. If the physician is not board certified, we must verify the highest level of education.
For Joint Commission Standards, we must verify all education, work and liability histories, hospital affiliations, all current and previous state licenses, DEA certificate and three peer references. We also query the NPDB and review any Medicare/Medicaid sanctions and opt-out lists. We also conduct office site visits for PCPs, OB/GYNs, mental health providers and any other high-utilization practices to ensure American with Disabilities Act (ADA) compliance and medical records review.
When all the data has been reviewed and found to have no issues, the file is presented to the Chief Medical Director for review and recommendation to the Peer Review Committee, which is made up of Lane Independent Practice Association physicians with various specialties. Monthly Peer Review Committee meetings are conducted to review and approve new and recredentialed applicants and to address physician complaints for any necessary action. The Credentialing and Peer Review Committee makes final participation decisions granted by the Board of Directors.
The credentialing process must be completed within 180 days of the date the application is signed; 120 days for organizations. Providers are recredentialed every three years for National Committee for Quality Assurance (NCQA) and every two years for JCAHO.
All peer review information is protected and confidential.