Figure 4.3 Sample Language for Proctoring Agreement with Third Party

(Note: This language is meant to assist in crafting a formal contract/agreement with a third party proctor—legal counsel should be consulted in creating an actual document.)

PROCTOR CONSULTING AGREEMENT

Hospital is a not for profit entity seeking assistance with its peer review activities from the clinical expert identified below. The use of the term Hospital in this document encompasses its medical staff. All requests for proctoring originate with the Hospital medical staff and proctoring under this agreement is considered peer review work done at the request of the medical staff.

This Proctor Consulting Agreement (“Agreement”) between Hospital and ______, a resident of the State of ______(“Proctor”) is effective as of the Effective Date as set forth below, and the parties agree as follows:

Proctor hereby accepts to perform such duties as are from time to time assigned by Hospital and accepted by the Proctor. This work shall be part of the Hospital’s medical staff peer review activity and shall be performed in conformance with the Hospital and medical staff policies on confidentiality. Proctor shall at all times faithfully and to the best of Proctor’s ability perform all the duties that may be required of Proctor to the reasonable satisfaction of Hospital.

Proctor shall review each case (either through chart review, direct observation of care delivery, and/or discussion with relevant parties) in accordance with Hospital’s instructions and complete and submit a final review according to the following schedule (“Turnaround Time”):

Standard review: submitted within X business days.

Specific reviews may require different Turnaround Times indicated on the review itself. If Proctor is not able to complete the assignment within the required Turnaround Time, Proctor agrees to deliver notice of such inability to Hospital within 2 hours of receiving assignment.

Proctor agrees to make 1 to 2 attempts to reach the attending Provider by telephone depending on the stated requirements of the specific review. Reviewer agrees to be available by telephone within a reasonable time period after submission of the completed review to discuss the results of any review performed by the Proctor with the attending Provider and/or ordering medical staff leader or committee.

All information submitted by the Proctor to Hospital will be correct and accurate to the best of the Proctor’s knowledge. All present and future communications and business transactions between the Proctor and employees or medical staff members of Hospital will be made through Hospital.

Proctor shall not accept assignment of a case if Proctor determines a conflict of interest exists. A conflict of interest is any relationship or affiliation on the part of Proctor that could compromise the independence or objectivity of the independent review process. Hospital will be responsible to make payment to Proctor with sixty (60) calendar days from the date the service was completed.

HIPAA Business Associate Agreement

Proctor and Hospital agree to comply by all applicable state and federal laws and regulations concerning the confidentiality of patient data. This includes compliance to the Standards under the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and in accordance to the HIPAA Privacy Rule.

Proctor Credentialing: Authorization Request for Information

Proctor consents to inspection by Hospital and their representatives of all documents that may be material to an evaluation of Proctor’s qualifications and competence.

Proctor agrees to inform Hospital of any change made or proposed in the status of professional license to practice, DEA or other controlled substances registrations, membership or clinical privileges at healthcare facilities, and on the status of current, or initiation of new, malpractice claims.

IN WITNESS WHEREOF, the parties have executed this Agreement as of the Effective Date, as set forth below.