Problem doctors sometimes “slip through the cracks” during the credentialing process. A thorough due diligence program will minimize such risks.
Physician recruiters are often placed in a Catch-22 situation. On one hand, recruiters are expected to present well-qualified candidates to their organization. On the other hand, a recruiter is not in a position to engage in a full-fledged credentialing investigation before a recommendation is made. That is normally done through a risk management program where an in-house staff or an outsourced credential verification organization (CVO) performs an in-depth credentialing process.
Consequently, despite having interviewed the candidate, checked references, asked about unexplained gaps in employment, and looked for the “red flags” that recruiters can spot from years of experience, it still comes down to an educated guess. A recruiter can only cross their fingers and hope that a candidate is who he or she appears to be once the risk management process begins.
Unfortunately, history shows that an unqualified candidate can get past the efforts of even the most experienced recruiter, even one who has reviewed thousands of candidates, conducted numerous interviews and has a well-developed professional instinct. Just because someone presents himself as a doctor by no means ensures that he is qualified, currently licensed, or ever has been licensed. Doctors, as individuals, are no more immune from problems and difficulties than any other group.
Physician recruitment has become more challenging in recent years due to increasing concerns over the qualifications and backgrounds of physicians. Financial liability for acts and misconduct of employees is becoming one of the most significant areas of exposure for health care organizations. The exposure occurs because a health care provider can be held liable for injuries resulting from failure to adequately screen the physicians it hires.
Recently there have been well-publicized cases where efforts to maintain physician standards have fallen through the cracks as physicians, or imposters, have caused untold damage. Courtrooms, state medical boards, and the popular media are increasingly becoming the venues where unfortunate and often tragic stories of healthcare providers failing to exercise due diligence are played out. The economic cost to the medical profession is staggering. And, there is no way to even calculate the cost in terms of negative publicity and loss of trust, as well as the pain and suffering caused to the victims and their families.
These dangers in physician recruitment are underscored by some startling statistics:
--According to the Federation of State Boards (FSMB), the representative organization for state licensing agencies, 4,569 actions were reported by the medical boards in 1999. Of the 4,520 total actions taken, 3,838 were prejudicial to the physician and were taken for violations such as quality of care, sexual misconduct, insurance fraud, alcohol/substance abuse or inappropriate prescribing of controlled substances.
--According to the Public Health Citizen’s Research Group in Washington, D.C., between 1984 and 1999, some 20,125 physicians were the subject of some disciplinary action by a state medical board or other governmental agency, resulting in nearly 39,000 disciplinary actions. Equally a matter of concern is the fact that more than 3,000 physicians were guilty of felony offenses. There is, of course, no way to calculate how many criminal violations were never reported.
Fortunately, recruiters do have tools available to make recommendations based upon verifiable and factual information. Some of these tools are easily available online. Other information sources are available as a practical matter only through professional information providers, because of the specialized skills, resources and knowledge involved. One source of assistance for a recruiter is a qualified pre-employment background-screening firm with knowledge of the needs of medical recruiters (For suggestions on how to select a firm to assist in screening, see the MedCAREERS article on “Outsourced Pre-employment Screening,” at http://www.medcareers.com/resources/resource.asp?audience=employer&id=1119).
There are a number of tools utilized by pre-employment screening firms. A federal law called the Fair Credit Reporting Act (FCRA) governs these background reports. A screening firm should be able to explain how the law operates, as well as provide the necessary written disclosures and consents required to run a due-diligence background check. It is a best practice to conduct all due diligence checks only after receiving a written consent.
- Database physician credentials report: The physician credentials report is drawn from a number of sources in order to give an overview of the professional status of a medical doctor. The report includes the full name, date of birth, gender, current location of a physician’s practice, educational background, states in which a physician is licensed to practice or has held a license, honors, specialty certificates, any sanctions imposed by the DEA, FDA or Department of Health and Human Services, and records concerning disciplinary action from 67 State Medical and Osteopathic Boards (covering every state in America). This is a “due diligence” credentials report. It is not intended to be used as a formal “credentialing process.” Although commentators have suggested strengthening of the standards in certain respects, both the Joint Commission on the Accreditation of Healthcare Organizations (JACHO) and the National Committee for Quality Assurance (NCQA) set forth very detailed criteria.
- Sanctions report: A qualified screening firm can obtain a comprehensive report on sanctions from various federal and state agencies that complies with federal requirements. Although a sanctions report may not have everything that a risk-management process may obtain from the National Practitioners Databank, it is a very valuable research tool. Two of the most widely accessed federal sanctions databases are the ones maintained by the Office of Inspector General (OIG) and the General Services Administration (GSA). These are both available online. However, a background screening firm can access a much more extensive database that gathers sanctions and official actions from over 700 sources.
- Criminal records check: A screening firm can search for criminal records in state and federal court in jurisdictions where a candidate has lived, worked or studied. This is a critical check for any healthcare organization. When private employers check criminal records, they normally do not have access to national governmental criminal databases (unless the position qualifies for a state authorized fingerprint check, such as teachers or child-care workers). Private employers can check criminal records only by going to individual courthouses and looking through the records that are kept by each court. Since there are more than 10,000 courthouses in America, contained in some 3,200 jurisdictions, a nationwide criminal check is not practical.
To determine where to search, employers will examine the resume or job application. They can also review records kept by credit bureaus that list addresses associated with Social Security numbers, and they need to verify past jobs to confirm where a person has been and to make sure that there are no unexplained gaps in employment. There are some state limits as to how far back searches can go, and most authorities recommend ten years (subject to individual state limitations).
When there is “no hit,” it usually takes 2-3 days to get a result back. A qualified background firm should be able to provide a listing of their anticipated turnaround time for every county in America. There can be delays, however, if there is a possible match; and the court clerk needs to pull the actual file to look for identifiers and to obtain case details. No one has any control over how long a court clerk takes to do that.
There are some “statewide” criminal record databases. Not every state has a statewide search available, and those that do are maintained in a variety of ways. As a result, these searches should not be utilized without great scrutiny as to how the data is gathered, how often it is updated, and how complete it is. Most experts recommend the “on-site” court searches as the best tool to exercise due diligence. A qualified background firm can tell a recruiter if a database exists and what value it has for a search in a particular state.
- National Wants and Warrants Search: Recruiters can access a national Wants and Warrants database through a qualified background firm. This search is composed of outstanding warrants placed in a central computer system. However, it only accesses a portion of the cases that are currently active, and it is not meant to be a substitute for a criminal history search.
- Social Security number trace: This search provides names and addresses associated with an applicant’s Social Security number, and may indicate any fraudulent use. It may verify other applicant information and helps a screening firm to select the counties where criminal checks should be performed. It also helps to verify applicants are who they say they are. This report is critical to ensure that employers are not the victims of a fraudulent application by someone with something to hide.
- Credit reports: Credit reports provide public records such as judgments, liens and bankruptcies, as well as a person’s credit history. It may also include previous employers, addresses and other names used. It is a tool some employers use to gauge trustworthiness and reliability. Credit reports are very sensitive for applicants, and should only be requested when it is specifically relevant to a job function, and the employer has appropriate policies and procedures in place to ensure that the use of credit reports is relevant and fair. Employers typically access a version of a credit report that is specifically for employment purposes. See an article previously posted on MedCAREERS.com entitled “Credit Reports and Job Hunting” (http://www.hiresafehealthcare.com/articles/article4.html).
- Civil court records: A civil record search will reveal civil lawsuits that have been filed against, or by, an applicant. The search can be in state court or federal court. State court suits are generally limited to upper or superior court cases. It may also reveal any lawsuit that can be related to medical positions that have not necessarily been captured by the National Practitioners Databank. An employer must determine if the lawsuits reflect any work-related issues that an employer may need to know about in order to make a hiring decision. For example, when hiring a physician, malpractice suits or suits alleging dishonest behavior or workplace misconduct may be relevant. If hiring a manager, allegations of sexual harassment or workplace misconduct could be relevant. An employer should avoid considering civil lawsuits that have no bearing on workplace conduct or don’t provide valid predictors of job performance. In addition, an employer should not consider any portion of a lawsuit that reveals information that cannot be the legal basis of a hiring decision (i.e., a lawsuit that may reveal religious preference or marital status).
- Driving records: A driving records search will generally give a history for three years, verification of driving privileges, other names used, and some level of identification verification. It is available to recruiters and employers from most states through a background firm. It also requires consent from the applicant. Although not a critical piece of information for a physician background check, it’s a fairly inexpensive inquiry when done as part of a background search, and can reveal helpful information. It can be utilized to give insight into an applicant’s level of responsibility, and whether an applicant keeps commitments to appear in court or pay fines. Because it is a true statewide search, it may be the first place an employer has as an indication of a potential drug or alcohol problem, if a driving under the influence charge should appear. By the way, “driving for work” is very broadly defined in most jurisdictions and is not limited to driving positions.
- Employment verification: Basic verification includes dates of employment, job title and reason for leaving. Some employers will verify salary. This is usually obtained from HR, Personnel or Payroll. Some employers have the information recorded on a 900 service. This information confirms your applicant’s resume and verifies previous job history. This search helps eliminate any unexplained gaps in employment, which ensures that appropriate jurisdictions have been checked for criminal records.
Employers are often hesitant to give recommendations and may limit prior employment checks to the basic information. This service can be limited if a background firm is not allowed to contact the current employer, if the past employer is out of business or cannot be located, or if the employee was working through an agency. It is recommended that all applicants for any position undergo a previous employment check for 7-10 years.
10. Employment references: This is a more in-depth reference check that seeks job duties, performance, salary, strengths and weaknesses, eligibility for rehire and other detailed information. It allows an employer to have a realistic assessment of a candidate from former employers. It promotes a better fit, confirms the hiring opinion and protects the expensive hiring investment. It is particularly valuable to know how a person has performed in the past, because that can be the best indication of how they will perform in the future.
Although most employers would like references, many will not give them due to concerns over legal liability. However, an employer should still attempt to obtain references in order to demonstrate due diligence. Overcoming an employer’s hesitation to give a full reference can be something of an art form. If a recruiter senses some hesitation, one approach is to not ask immediately about job performance, but to instead ask for a description of the duties and responsibilities of the position held. That can naturally lead into a discussion of the particular applicant.
11. Education and credentials verification: Recruiters can also get on the phone and verify past education and professional licenses and credentials. Numerous web sites will help provide the necessary phone numbers. In addition, a qualified background firm can also be used to assist in this process.
12. Sexual offender databases: Another source of information is sexual offender databases by various state and local jurisdictions. They are not available to employers in all states. Some of the databases are easily available over the Internet, such as http://www.sexoffender.com/search.html. There can also be limitations on their use in some states for employment purposes.
Recruiters for hospitals and healthcare providers should consider taking extra steps and engaging in a program of pre-employment screening. The old saying about an ounce of prevention certainly holds true in this critical area. Any hospital or healthcare providers who have found themselves involved in a situation involving a “bad” doctor would have paid anything to have avoided it. Taking into account the tremendous risk and costs of just one bad hire, the minimal extra time, effort and expense in exercising due diligence through background screening has proven to be a very wise and prudent decision.
Les Rosen is an Attorney at Law and President of Employment Screening Resources, headquartered in Marin County, CA. For more information on his firm’s services, visit www.ESRcheck.com or the Services section of MedCAREERS.com.