Credentialing and Medical Privilege Disputes
Our Georgia business and healthcare law firm, with offices in Atlanta and in the Medical District of Augusta, GA, advises and represents physicians and other healthcare providers and professionals in credentialing and peer review matters and litigated disputes. We are an AV-rated boutique law firm focused on the healthcare industry.
Atlanta/Augusta, Georgia Physician Credentialing Lawyers
“Credentialing,” as that term is typically used in the healthcare industry, can refer to the medical credentialing process and the criteria applicable to, for example, a physician’s participation within a health plan or appointment to a hospital’s medical staff. The credentialing process is now an integral part of healthcare practice today as an important way to verify the qualifications of clinical practitioners. Credentialing practices and requirements vary somewhat by locale and practice setting, with nuances in law and process depending on the State of practice. Although the details may vary according to the particular circumstances, the credentialing process typically involves a few steps, including:
- Keeping updated contact information for all providers on staff;
- Providing a checklist of information required of physicians in obtaining credentials at a practice site;
- Planning ahead to perform a timely and detailed background check, and verifying its accuracy with listed references, former employers, medical associations, federal agencies and state boards;
- Requiring peer references and checking them;
- Investigating prior malpractice claims that may suggest heightened scrutiny for providers with those issues.
- Submitting the credentialing application to the practice site’s governing body for final review. For more information and additional steps, see http://www.beckersasc.com/asc-accreditation-and-patient-safety/10-steps-to-a-thorough-physician-credentialing-process.html
Some States, such as Georgia, through their medical boards and other cooperative hospital and healthcare associations, have developed standardized forms to facilitate efficient credentialing processes across disciplines. Although not required to participate, Georgia hospitals and health plans almost always accept the uniform application. See: http://www.georgiacredentialing.org/index.html
Disputes that can arise impacting the credentialing and scope of practice of medical staff include:
- Allegations that a physician has breached a contract or otherwise failed to follow medical staff bylaws
- Negligent credentialing actions by a third party who asserts that a hospital or other practice site failed in its medical staff bylaws or peer review processes by allowing an unqualified physician to perform services
- Physician disputes as to hospital decisions to deny medical privileges based on improper criteria (unrelated to quality of healthcare, treatment and services)
Georgia courts have held that although hospital bylaws, by themselves, do not constitute a contract between the hospital and the doctors, nevertheless a hospital is bound by the bylaws it creates. If a hospital does not follow the procedures in its bylaws, a Court can require the hospital to follow those procedures. Robles v. Humana Hosp. Cartersville, 785 F.Supp. 989, 1001 (N.D. Ga. 1992), St. Mary’s Hosp., Inc. v. Radiology Prof’l Corp., 421 S.E.2d 731, 726 (Ga. Ct. App. 1992).