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Consequences Associated with Risk Exposure to the 5 Critical Data Gaps in Health Care Compliance

January 17, 2019

While it should naturally be every health care organization’s practice to properly vet and monitor every employee, provider and entity, the regulatory environment has put laws and guidelines in place to help the industry reach and sustain standards. However, simply meeting minimum requirements can still place you at risk for fraud, which can lead to patient endangerment.

Without obtaining and sustaining a 360-degree view of every relevant individual and entity you are putting in front of your patient base, your organization, reputation and patients can be exposed to risk.

This guide is designed to help those whose job it is to screen, verify and monitor its entire staff population, as well as partners and suppliers of goods and services. This Gap series will help users come to terms with the most critical data gaps and overcome the elusive nature of quality data and data delivery and storage. Further, the series will help users understand how to gain access to the best data and data delivery platforms in the industry.

The data marketplace is filled with products, interfaces and search engines. But just like the food-service industry, the quality of the ingredients and the preparation distinguish one dish from another. A background search with results rendered from old or partial data, will inaccurately portray the nature of the candidate.

The consequences range from lawsuits to patient injury, federal fines, reputational damage, and routinely losing ground to administrative inefficiencies.

  • Risk to patient safety: Patient safety is at risk when physicians, allied and skilled health care workers, or contractors with access to patients, have prior evidence of a lack of credentials, incompetence, negligence, or abusive and disruptive behaviors join or are allowed to remain in an organization.
  • Liability for negligent hiring: Health care organizations are responsible for uncovering adverse background and current information such as license disciplinary actions, abuse, fraud, exclusions, debarments, sanctions, civil malpractice, or criminal behavior in the screening process before hiring. Failure to properly vet the people and businesses engaged by an organization can result in legal liabilities, reputational damage and a compromised patient experience.
  • State or federal sanctions and penalties: Penalties can be severe for organizations that rely on incomplete, outdated or inaccurate data sources in the screening, primary source verification and monitoring processes.
  • Violation of standard-setting organization requirements or failing to adhere to internal policies and procedures: An organization’s failure to collect, verify, share and monitor professional and performance data in accordance with internal bylaws, policies and procedures as well as agreed-to standards (The Joint Commission, DNV, HFAP, NCQA or URAC) on an ongoing basis—such as license expirations, lawsuits and judgments—can lead to serious consequences.

Long-Term Reputational Damage Can Far Exceed Near-Term Costs

The costs of missed information or negligence throughout the credentialing process and retention practices can be substantial. At play are legal liabilities, fines and other direct costs. The damage of a highly publicized incident that could have been prevented by using reliable data sources and advanced technology, presents irreparable damage and great expense.

Reputational risk is real and tangible. As health care organizations vigorously compete to grow patient loyalty as well as staff and referring physicians, one adverse event can devastate a hard-earned reputation and significantly impact revenue by patient attrition and the ability to attract and retain key talent.

Headlines Reveal When Transparency in Health Care is Ignored

Public media has revealed many egregious instances of provider harm due to failure to properly vet health care practitioners:

VA failed to report 90% of potentially dangerous medical providers, GAO confirms 

Thousands of doctors practicing despite errors, misconduct

Recent high-profile medical malpractice cases where undetected sanctions against physicians caused significant reputational damage demonstrate the importance of performing a thorough review of providers applying for employment or engagement and following with continuous monitoring.

The following are examples of incidents and recurring behaviors that could have been prevented or cut short by checking FACIS®, the gold standard in Compliance and Verisys’ database of exclusions, sanctions, debarments and disciplinary actions (both current and historical).

Turn-key technology platforms, like CheckMedic® would have flagged bad behavior with its access to some 5,000 primary source publishers and continuous real-time monitoring. By checking important data sets including DEA, FACIS®, national licensure, national abuse and sex offender registries, along with other sources of data; behavior such as state hopping, violent or criminal acts, and fraud can be identified proactively. Thus, preventing these scary realities.

In the case of Dr. James Kohut, FACIS® showed disciplinary actions dating back to 2005 including board orders and license revocation actions in 2012 and 2014. Yet, Dr. Kohut continued to practice until he was caught sexually abusing children in addition to two nurses he worked with in 2018.

Dr. Binh Chung drugged and raped unconscious patients and was caught in 2017. FACIS® shows previous adverse actions dating back to 2009.

FACIS® shows Lawrence I. Miller was historically excluded for offenses related to distribution of controlled substances. Accessing and acting on accurate historic and current data sources would have prevented illegal distribution of opioids.

Dr. Stephen Chalker, pharmacist, defrauded federal programs of some $5 million in a compounding scheme. CheckMedic® systematically flags high-risk behaviors on entities. For instance, this pharmacy obtained a business license in 2011 and immediately changed the filing address—a flag indicating further investigation. The entity then voluntarily dissolved and submitted to revoke dissolution and changed the agent/owner and addresses.

All of these actions are red flags indicating financial and compliance risk.

Entity verification and management with FACIS® and technology like CheckMedic®, would have captured the warning signs avoiding this loss to Medicare, Medicaid and TRICARE.

The Root of the Problem: Processes, Data Sources and Systems that Are Not Producing Complete Information

HR, Medical Affairs/Staff Services and Compliance departments typically screen applicants and verify credentials and licenses using manual searches of individual databases or third-party software systems that simply store data from a limited quantity of sources and jurisdictions.

Unfortunately, gaps in this approach often prevent getting a complete, current and accurate story.

Why? The information needed for a complete screening and credentialing check is dispersed among thousands of databases from local, state and federal bureaus and agencies, plus independent professional organizations and boards. The complexity and lack of connectivity between sources can lead to major problems, such as granting privileges to a doctor with an undiscovered exclusion, debarment or disciplinary action; or hiring and retaining health care workers with adverse background issues or expired licenses.

It is therefore imperative for organizational leaders and professionals to recognize and take affirmative steps to close these gaps in their own in-house credentialing and sanctions/license screening, verification and monitoring processes.

It’s Not Only What You Know, It’s What You Don’t Know

Up front: One of the greatest risks to an organization is information that is either intentionally or inadvertently omitted. Huge gaps in data create big problems for organizations when processes are narrowed jurisdictionally and employ too few data sources, often without the benefit of aggregated data and augmented technology. It is impractical to individually search thousands of sources, which means critical data is missed. Further, point-in-time single searches miss historical content contained in longitudinally aggregated data sets like FACIS®. This very typical gap prevents obtaining a complete view of the applicant’s current as well as historical professional record and background.

Post-Hire Monitoring: The second biggest risk is the “one and done” approach. One can perform the best screening and credentialing effort and move on to hire or engage. Once hired or engaged, if your organization is not monitoring every employee, contractor or affiliate, you are placing your organization at grave risk. In any given year, approximately 8% of your total population will have a non-disclosed adverse action: from criminal and sex offender to exclusion, debarments and professional discipline. Monitoring will identify those gaps.

Part 2 of “Achieving Transparency Through Closing Five Critical Gaps in Credentialing”, is brought to you by Verisys Corporation, creator of the most powerful health care data platform delivered by cutting-edge technology providing full transparency that protects your reputation and your patients. The e-book, “Closing the Five Critical Gaps: A Guide to Understanding the Issues and Using Data Technology to Improve Provider Transparency to Protect Patients and Reduce Risk” is available to download here.

Verisys, a technology and data company, has created powerful turn-key solutions to close the gaps in health care data

Verisys is the leading choice to help you assure patient safety and positively contribute to the quality of U.S. health care through the mitigation of fraud, waste and abuse by providing full transparency on those in the health care system.

As an NCQA Certified and URAC Accredited Credentials Verification Organization, Verisys manages all data reports as a Consumer Reporting Agency abiding by federal law set forth in the Fair Credit Reporting Act. Verisys stores and exchanges data from a Tier 3+ secure environment, assures 99.9+% identity resolution accuracy 99.9+% of the time and assures its promises with full indemnification.

Verisys earned and sustains compliance with two international quality standards, ISO 9001:2015, certified for quality of credentialing software and background screening; and, ISO 27001, certified for highest standards of information security and data protection.

The sum of these certifications and accreditations ensures that promises made are promises kept to the world’s highest standards.

Verisys is the leading choice to help you assure patient safety and positively contribute to the future of U.S. health care through the mitigation of fraud, waste and abuse by providing full transparency on those in the health care system.

Contact us for a conversation about full implementation, or a staged rollout of screening, verifying and monitoring your health care workforce. 888-837-4797. info@verisys.com