NEW HAVEN COMMUNITY MEDICAL GROUP

YALE-NEWHAVENHOSPITAL

DEPARTMENT OF PHYSICIAN SERVICES

PROFESSIONAL LIABILITY & ADVERSE ACTIONS GUIDELINES

Purpose:

To ensure that all contracted providers meet the Professional Liability and adverse action guidelines set forth by the New Haven Community Medical Group. The NHCMG requires that during the credentialing and re-credentialing process, all members disclose professional liability and adverse action history for the past ten years including history regarding licensure, narcotics certification and other regulatory actions including Medicare and Medicaid sanctions.

Scope:

All new applicants to the NHCMG and members going through the re-credentialing process will complete a “Practice History Survey” and attest to its accuracy. The Practice History Survey includes questions regarding the status of the provider’s malpractice, licensure, medical history, narcotics certification, mental status and drug usage.

Information self-reported by each provider on the Practice History Survey, in addition to that obtained via query of the National Practitioner Databank, Federation of State Medical Boards, and Office of Inspector General will be reviewed according to the following Policy/Procedure.

Policy/Procedure:

Malpractice

1.During the credentialing and re-credentialing process, the NHCMG requires that all open and closed cases alleging professional liability or malpractice brought within the last ten years be reviewed by its designated, retained or contracted legal review agent.

2.In performing the review, the agent will examine the information provided and determine if it is current and reasonably complete (taking into consideration that the litigation may be pending and provider statements are discoverable.) The professional liability history will be analyzed for repetition involving fact patterns or allegations which would require further review by the Credentials Committee. In this examination, lesser weight will be placed on cases in which no payment was made on behalf of the provider (if the matter is resolved) or in cases which are brought as class actions (i.e. breast implant litigation).

Upon receipt of information from the agent that the professional liability history of a provider requires further review, the Credentialing Committee may request further information from the provider. This may include permission to contact the lawyer representing the physician in the litigation and a review of documents such as the lawsuit, deposition testimony and any settlement agreement. Based upon this review, the Credentials Committee shall determine if the provider shall be recommended for new or continued membership.

Licensure

1.Any provider whose professional license to practice in Connecticut is suspended or revoked will be immediately suspended from the NHCMG. A provider whose license is revoked will be terminated from the NHCMG and may re-apply for participation if the license is restored. If the license is suspended, the provider will be suspended from participation until the license is restored and the Credentials Committee has had an opportunity to review the allegations and facts of the suspension to determine if continued membership is appropriate.

2.Any provider who has a professional license which is restored or retained subject to a consent order or any other restriction(s) will be individually reviewed by the NHCMG legal agent and the Credentials Committee. If the physician is to be credentialed or re-credentialed, he/she will attest that the conditions of the consent order or restriction are being met. If those conditions include medical, physical or emotional, or impaired provider therapeutic intervention, the providerwill authorize the treater to supply periodic letters stating that the provider remains in compliance with the order or restrictions and continues to be able to practice with reasonable skill and safety.

Narcotics Certification

The NHCMG does not require all providers to possess authority to prescribe narcotics; only providers in practice specialties in which such certification to prescribe controlled substances is prudent are required to hold this authority. If a narcotics permit (state or federal) is suspended, revoked, or surrendered under pressure of further regulatory action, the Credentials Committee will review the circumstances under which this action took place in order to determine whether the provider’s membership in the NHCMG should continue. If a narcotics permit (state or federal) is restored or retained subject to a consent order or any other restriction(s), the provisions of #2 (Licensure), above, will be followed.

Medicare/Medicaid Sanctions

The Office of Inspector General Cumulative Sanction Report and EPLS are received and reviewed on a monthly basis. The Medicare Opt Out List is reviewed on a monthly basis as well as prior to credentialing and recredentialing.Any provider who reports, or is found, to have been sanctioned by the Medicare or Medicaid programs shall supply information about the circumstances under which this action was taken. The Credentials Committee shall review the information supplied along with any other information needed in order to determine whether the physician should continue his/her membership in the NHCMG.

Quality Deficiencies

The prior sections outline the actions the NHCMG will take in response to information it receives from external agencies or organizations with respect to licensure, malpractice, substance abuse or other areas of concern relative to the delivery of quality patient care. These issues are reviewed and addressed on an on-going basis upon occurrence.

The NHCMG and Yale-NewHavenHospital cooperate with each other in identifying, evaluating and remediating, if possible, providers who demonstrate one or more serious deficiencies in the quality of care they deliver. The NHCMG supports the YNHH's Medical Staff Health policy process where the quality deficiencies may be health related; this policy includes regulatory reporting if required.

Individuals identified through the NHCMG and/or Hospital processes for assessing quality of care, including but not limited to peer review (see Y-NHH Policy on Peer Review) and quality monitoring, as potentially demonstrating serious deficiencies in care provided, are evaluated further by both parties. This process may include, but is not limited to, case review(s), review by the Hospital/NHCMG counsel and the Chief of Staff, review by an ad hoc NHCMG committee and discussion(s) with the provider.

At the conclusion of the evaluation process (which can include immediate Medical Staff suspension, accompanied by suspension from the NHCMG), the Hospital may choose to modify, suspend or terminate Medical Staff privileges and will notify the NHCMG of any such action.

Regulatory reporting may be required during or at the conclusion of this process. If required, reports will be made to the National Practitioner Data Bank via websiteand/or to the Connecticut Medical Examining Board (or other appropriate Connecticut licensing authority).

The NHCMG Credentials Committee and the NHCMG Board of Directors are notified when evaluations are indicated and participate as indicated. The NHCMG will suspend or terminate individuals identified as having serious quality of care deficiencies regardless of whether regulatory reporting takes place.

Providers suspended or terminated due to the above may appeal the decision consistent with the NHCMG’s “Termination and Suspension Policy”.

Policy C

Updated: 12/02/02

Updated:2/22/00

Reviewed: 7/29/02

Reviewed: 08/23/04

Revised: 10/12/04

Revised: 12/29/09

Approved: 1/27/10

Revised: 1/19/11

Approved: 3/22/11