Department of Health and Human Services

Office of Inspector General -- AUDIT

"Review of the Policies and Procedures for Medical Personnel Credentialing and Privileging at the Indian Health Service, National Institutes of Health, and Health Resources and Services Administration," (A-15-94-00006)

December 16, 1996

Complete Text of Report is available in PDF format (1 mb). Copies can also be obtained by contacting the Office of Public Affairs at 202-619-1343.

EXECUTIVE SUMMARY:

This report provides the results of an Office of Inspector General (OIG) review of policies and procedures for medical personnel credentialing and privileging in the Indian Health Service (IHS), National Institutes of Health (NIH), and Health Resources and Services Administration (HRSA).

The objectives of our review were to assess the adequacy of Federal policies and procedures for credentialing and privileging:

1. in IHS and NIH direct care facilities; and
   
2. in nonfederally operated, community-based programs that receive funding through contracts and grants with IHS and HRSA.

The credentialing and privileging policies used by facilities operated directly by IHS and NIH are adequate, but Federal credentialing and privileging requirements for nonfederally operated IHS and HRSA funded community-based programs need to be strengthened.

Finding 1

The credentialing and privileging policy prescribed by the Public Health Service Interagency Advisory Council on Quality Assurance and Risk Management (Interagency Council) compares favorably with other governmental policies and professional literature publications. Further, both IHS and NIH have credentialing requirements that meet or exceed the minimum level established by the interagency policy.

 

Finding 2

In contrast, nonfederally operated, tribal health care programs funded by IHS are not required to follow IHS' credentialing and privileging policies. In addition, HRSA provides its grantees limited policy instructions on appropriate credentialing and privileging steps. Without adequate credentialing and privileging policies, the Federal Government risks increased liability for acts of malpractice that occur in these programs. Therefore, it is incumbent upon IHS and HRSA to encourage their fi-mded programs to adhere to stringent credentialing and privileging requirements.

 

Finding 3

 

The IHS and HRSA are also not required to determine whether providers they hire are excluded from being reimbursed by the Federal Medicare and State Medicaid programs. By not conducting a search of the exclusion list, IHS and HRSA run the risk of employing health care professionals who have been convicted of crimes relating to ethical or professional wrongdoing.

To strengthen requirements and provide more specific guidance on credentialing and privileging to community-based programs receiving Federal funding, we recommend that:

• the Director of IHS advocate programs for quality and risk management, specifically those related to credentialing and privileging of medical personnel in self-determination tribal health care programs;
  
• the Administrator of HRSA disseminate detailed information on the operation of a comprehensive credentialing and privileging program to community, migrant, homeless, and public housing health center grantees;
  
• the IHS and HRSA modify their employment or credentialing policies and practices to require, as a routine procedure, a search of the Department of Health and Human Services (HHS) OIG Medicare and Medicaid exclusion list; and
  
• the Interagency Council revise its credentialing policy to require a search of HHS' OIG Medicare and Medicaid exclusion list.

In responding to our draft report, IHS, HRSA, and NIH concurred with our findings and recommendations.