Brian Lund (BL): They definitely have evolved. Facilities are becoming more selective as to the type of physicians with whom they will contract. As a result, we have shifted from having physicians credentialed by the malpractice insurance carrier to performing the function in-house.

Anne Anderson (AA): Also, we are starting to see morecontractual risks. For example, some clients might requeststaffing agencies to provide workers' compensation for locum tenens physicians, but that is not appropriate because these physicians are independent contractors, not our employees. We need to make sure the relationship between all parties is properly explained on all contracts.

What are the specific responsibilities of a risk management department?

BL: Our risk management department is responsible for setting forth the criteria physicians must meet in order to be placed under our medical malpractice insurance policy. The criteria includes expectations with respect to board certification, number of clinical contact hours, past medical malpractice claims, and total indemnity payout on all claims.

Sarah Sebesta (SS): Our department also happens to set up travel arrangements and facilitate hospital privileges, as well as assisting in the licensure process.

What does the candidate screening process entail, and what role does risk management play?

Neeraj Uppal (NU): A comprehensive credentials review is performed for every locum tenens physician and non-physician provider. All information is verified directly with primary sources in compliance with the standards of the National
committee for Quality Assurance (NCQA) and The Joint Commission. Since physicians' risk profiles are determined by the quality of their medical abilities, these programs ensure that only the most qualified candidates are placed on contracts. We minimize risks by consistently addressing suitability of matches. This assessment goes well beyond just credentialing because it also considers what one might call the softer side of staffing, like temperament, management style, and personality issues.

AA: But first comes the initial contact with recruiters. They send out an application that asks some basic questions about education, training, and claims history. After reviewing the information with the provider, the recruiter will pass the information to the risk management department. The risk management department then takes that information and delves deeper, such as contacting each state licensing board to verify status of their licenses. We also check with the American Board of Medical Specialties if they are board certified, and we write to the medical schools and residency programs to confirm their education history. Additionally, we look at physicians' Medicare and Medicaid billing, federal Drug Enforcement Agency results, and new references. We typically use our opportunity evaluations as references because we think our clients are the most objective judges of how our locum tenens physicians perform.

Susan Collier (SC): At our company, credentialing reflects an intensive background check in areas of training, education, sanctions history and malpractice risk. Medical staff applications are examined very closely and credentials are verified with primary sources. For example, we request references from colleagues within the same specialty who have practiced with the candidate within the last 18-24 months, preferably in a supervisory position.

BL: We also review each application for loss of medical licenses, felony convictions, loss or limitation of privileges, and review of disciplinary actions. These all require further explanation. Physicians are asked to submit complete CVs with the last 5 years detailed and any gaps of 30 days or more explained. Often, doctors want to know why we need so much information, but I think the process speaks for itself. We take it seriously in order to protect all parties and to provide the best experiences as possible.

SS: Once we have all the necessary information verified, then the candidate is presented to facilities. If the physician is accepted, the opportunity is booked. That is also when additional departments step in to confirm pay rates, travel arrangements, and housing accommodations. The privileging department gets to work with the hospital medical staff office to secure privileges in time for the opportunity to get underway.

What is the difference between risk management and quality assurance?

SC: In our company, we have two different divisions. Quality management focuses on practitioner competency and clinical practice assessments, whereas risk management focuses on professional liability placement and claims administration. You can think of quality management as the underwriting side and risk management as handling professional liability claims. Our quality management department consists of clinicians—primarily registered nurses—and a physician medical advisory board. The broad responsibilities of the quality management department are to set corporate credentialing standards, assess practitioner qualifications, conduct clinical investigations, assess practice settings, and comply with regulatory bodies, such as HIPPA, NPDB, OSHA, etc.

SS: If there is someone who might be questionable because of frequent or serious malpractice lawsuits, then the final approval has to go through quality assurance along with having a conference with our malpractice insurance company. The bottom line is that we do not want to send someone on an opportunity who is not a legitimate candidate. That is why we go through all of the painstaking verification. We have to make sure we are performing our checks and balances.

How long does credentialing take before physicians are presented to contracting facilities and solo or group private practices?

AA: Twenty years ago, there was no Internet and you physically had to write letters to every primary source, and then wait for replies. Now, you can verify credentials online in minutes. That has been instrumental to the locum tenens industry because most of our placements have a sense of urgency to them.

NU: One of the many benefits of having an internal NCQA-certified credentials verification organization (CVO) is the ability to quickly credential physicians. This process usually can be completed in a matter of days, sometimes even the same day. Some temporary engagements, particularly with federally operated facilities, may take longer, depending on the requirements of the individual hospital.

What role does risk management play with regard to the malpractice insurer?

SC: One of the activities utilized to assure the quality of practitioners and reduce the risk of negligent care is the implementation of a credentialing program. For the past 10 years, every malpractice insurance company has asked for documentation of our

credentialing program. Even then, they may still do a separate audit to verify compliance to our established credentialing policies and procedures.

AA: We make sure physicians obtain malpractice insurance. They are named to our corporate policy and we take care of the administrative functions. In the event of a claim, we are the liaison between the physicians and carrier.

What happens if something arises between locum tenens physicians and healthcare clients during a contract?

SS: We believe in full disclosure from the onset because hospital administrators review locum tenens physicians' credentials too, and we do not want them coming across any surprises. We would rather present any possible concerns, such as, "This physician had a malpractice suit and this is what resulted, but check out his references."

NU: During the contract, recruiters and client managers continue to be receptive to indicators of future problems and address them as they arise. Most losses occur due to the accumulation of any number of factors, not only because the physician was negligent. We assemble service teams that probe into the causes of problems that may have occurred. Reviewing these incidents often provides us with a clear picture of the factors that created the circumstances; and valuable information can be gleaned from this data that can lead to better decision-making in the future.

BL: As risk managers, we do not have clinical expertise, so we have a risk review committee that oversees such situations. In worst-case scenarios when a physician is released midway through an opportunity, we ask for written statements explaining what transpired from both the physician and contracting facility. If it is something simple, like tardiness, we can usually resolve it rapidly. But if the issue is alleged poor patient outcomes, then the risk review committee is convened to make the best decision possible.

Also, part of risk management is to make sure we are placing physicians in safe settings. From time to time, we take clients through the review processes. We want to know why they are asking for locum tenens physicians. Is it because doctors are on vacation or have taken sabbaticals, or is it because the facility's license has been suspended? If it is the latter, then we could be putting physicians into a bad situation and we do not want to take that chance.

AA: From time to time, we hear from physicians that something is happening at their contract facility that they are uncomfortable with, and that is when we step in as their advocates. This type of situation may come up periodically, but it is usually easily resolved. In most incidents, it is a matter of personality or miscommunication—for whatever reason, the client's and doctor's styles are not meshing. In the worst-case scenario, the physician leaves, but that is rare.

How does having a risk management program in place benefit locum tenens physicians and healthcare clients?

BL: Our risk management program greatly benefits our clients because every physician's credentials are reviewed twice—once by us and another time by the client. This is a great checks and balance tool. It is important to say that we have two clients: the hospital and the physician, and we try to make the best decisions in the interest of both of our partners.

SC: We continue to acknowledge the importance of an effective credentialing program as one dimension of quality/risk management in healthcare organizations. Credentialing activities should contribute to the identification of quality providers, and subsequently, quality providers should provide quality care and services to patients. Also, because we're a CVO, some clients have elected to delegate all or some of the credentialing responsibilities to our company. From the perspective of practitioners, this overcomes the greatest source of their dissatisfaction with credentialing, which is the redundancy among the application requirements of credentialing entities.

NU: Our risk management department is closely aligned with our CVO and the credentialing process. About a year ago, we made a strategic decision to create an independent risk management capability. We recognized the increasing complexity of the challenges our physicians and clients face and realized this expertise would be the ideal way to add value to our service.

This is an area that holds great potential for enhancing the locum tenens experience. We believe that as the temporary staffing option continues to become an increasingly important and acceptable part of facilities' personnel strategies, opportunities for collaborating on risk management issues become increasingly attractive.

MANAGING THE FUTURE

As the locum tenens industry grew throughout the years, staffing agencies worked closely with healthcare facilities and private practices to establish a consistent set of credentialing standards. This has probably been one of the biggest contributing factors to improving the overall acceptance of this practice alternative. As time continues to tick onward, the responsibility falls to risk management departments to further evaluate and adjust policies and procedures to assure physicians, non-physician providers, and contracting organizations are protected from as many unknown elements as possible.

Areas requiring primary source verification

1. All active, inactive, and expired state licenses, including any sanctions x State-controlled substance registration
2. Federal Drug Enforcement Agency registration x Specialty board certification
3. National certification (for mid-levels) x Education history
4. Medicare and Medicaid sanctions

Streamlining the process

Keeping organized files that document every locum tenens opportunity, with hospital affiliation, address, date, and agency name on your CV can definitely save time and avoid confusion. If you have gaps in your permanent employment, include a reference who can attest to why time was taken off. And be prepared to provide a written explanation of any issues in your educational, training, or licensure histories.

Special thanks to Sarah Sebesta, manager of risk management for Dallas-Texas based Delta Locum Tenens for providing the background information on this topic.

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