1. CREDENTIALING “RED FLAGS”
The vast majority of applications for appointment and/or clinical privileges raise no issues and present little risk of negligent credentialing.
However, certain types of information submittedin an application (“redflags”) may warrant greater scrutiny. If a healthcare organization
wishes to credential a physician with a “red flag” in his/her background, the organization shouldconsider additional analysis that explains
why such action was reasonably warrantedunder the circumstances. Doing nothing or failing to further address a red flag in an application
may expose the organization to negligent credentialing liability if the unaddressed concern leads to an adverse patient outcome. Although red
flags do not automatically preclude a practitioner from appointment andclinical privileges, the Medical Services Professional (MSP) should
perform a comprehensive review of a practitioner with any red flags, keeping in mind the relativity among different specialti es, patient safety,
and likelihoodof lawsuits. The following are examples of redflags:
APPLICATION FORM
 Incomplete areas or unanswered questions
 Discrepancies between information
received from applicant and references or
verified information
 Inability to verify information disclosed on
application
TIME GAPS
Gaps in the application should be viewed with
suspicion and follow-up requests for
information are warranted. An applicant with
“red flags” in his/her background may try to
avoid a healthcare organization’s “red flag”
tracking system by omitting such information
from the application.
 Periods of time unaccounted for
 Information reported by applicant that
does not matchtimeline or information
reported by organizations with which
applicant is or was affiliated
 Unexplained lapses or gaps in training
and/or practice
 Gaps in CV, particularly related to
employment and medical staff membership
TRAINING
 Failure to complete a residency training
program
 Extra time needed to complete a training
program
 Applicant changed medical schools or
residency programs or has gaps in training
 Multiple education institutions,
residencies, fellowships
LICENSURE/REGISTRATION
 Information indicating that the applicant
holds a license in another state that was not
listed on application
 Documentation provided by applicant does
not show that he/she ever practiced,
trained, or otherwise had a need for a
license in that state
 Disciplinary actions or pending
investigative proceedings
 Loss of licensure/registration (e.g., DEA)
 Restricted licensure/registration
 DEA: Lack of or limitation of schedules
BOARD CERTIFICATION
 Out of training for a period of time and not
board certified
 Repeated failures to obtain board
certification
PRACTICE HISTORY
 Applicant has moved significant distances
or has moved frequently during his/her
professional career
 Change of specialties
 No response to a reference inquiry from a
medical group, managed care entity,
training program, or professional society
with which the applicant has been
affiliated
 Responses from healthcare organizations
and/or employers simply give dates of
service or very limited information (as in
Kadlec, it was factually correct but still
misleading and incomplete)
 Applicant has been removed from a
managed care panel
 Applicant has resigned as a partner from a
group or ended an employment
arrangement with a healthcare facility
 Reports of problems in the applicant’s
professional practice
PEER REFERENCES
If one of the following red flags occurs, have
a physician leader follow up with the peer
reference via a phone call. The MSP or
Credentialing Specialist should be present
while the phone call is being made; there
should be complete documentation of what
the peer reference conveys during the
conversation.
 One or more reference responses that raise
concerns or questions
 Category ratings of “Poor”, “Fair”, or
“Average”
 Reference letters are neutral
 Non-responses, questions not answered,
or “iffy” responses from peers
 Vague or unduly narrow answers from
references
 References that refuse to complete a
detailed evaluation
 Inability to provide references that can
attest to current clinical competence (i.e.,
have knowledge of the applicant’s practice
within the previous 24 months)
 Comments about behavioral problems
MALPRACTICE/LIABILITY
 Little or no verified coverage from a
professional liability insurance policy
 Unexplained gaps in coverage, change in
carriers, or reduction in coverage
 2 or more (or an unusual pattern) of
malpractice cases filed within the past 5
years OR one final adverse judgment in
a professional liability action in excess of
a particular monetary amount (defined
by your organization)
 Change of insurance carriers several
times in recent years
HEALTHCARE ORGANIZATION
AFFILIATIONS
 No response to a hospital affiliation
verification request or reference request
from an applicant’s past affiliation
 History of disciplinary actions or
pending investigative proceedings by
medical staff organizations in healthcare
organizations
 Involuntary termination of medical staff
membership or involuntary limitation,
reduction, denial, or loss of clinical
privileges at another organization
 Ended an employment arrangement
with a hospital or healthcare
organization
 Resignation from a medical staff at any
time in applicant’s career
 Inability to maintain a medical practice
within the organization’s service
jurisdiction for any amount of time
OTHER
 Adverse NPDB report
 Excluded from Medicare/Medicaid
programs
 Any claims or investigations of fraud,
abuse, and/or misconduct by
professional review organizations or
third-party payors, or government
entities, such as Medicare and Medicaid
 Applicant has potentially relevant
physical, mental and/or emotional
health problems
 Other reasons as determined by a
medical staff leader or other
representatives of the healthcare
organization which raise questions
about the qualifications, competency,
professionalism, or appropriateness of
applicant for membership or privileges
 Criminal background