TAKE CHARGE Incomplete physician credentialing files are one of the most common deficiencies during on-site inspections.

A physician you've been courting for months suddenly wants to bring a juicy lineup of cases the day after tomorrow. One not-so-small problem: You haven't a single document from this star physician. And your credentialing person is on vacation. What's a facility manager to do?

Create a checklist of required documentation. Your checklist should include everything that your medical staff bylaws or credentialing policies say you'll include in each credentialing file. If your policy says you'll get 4 peer reference letters, make sure you have 4. If it says you require hospital privileges at a hospital within X miles, know which hospitals are within that distance and have that documentation for each physician.

Use the checklist. Don't have it sitting in the file half-completed. When you get documentation (say, a DEA certificate), don't just check off that item and put the document in the file. Be sure your copy is current and legible. Check your application to see if the applicant answers yes to questions such as "Have you been involved in litigation within the last ____ years?" If an applicant says he's had lawsuits, get an explanation and make sure your medical director reviews and initials the document to show he's seen it. Review everything you get. I've seen a nurse's license in a credential file that had a handwritten expiration date.

Verify all that you can verify. Always tell yourself, "Trust, but verify." You can do online verifications of DEA certificates, state licenses, fluoroscopy certificates (in California), board certificates and OIG status. Bookmark these websites on at least 1 computer to make this process quicker. Many hospitals allow online verifications of physicians' hospital privileges. It only takes finding the website for the hospital and 1 call to the medical staff office to ask if there is a password that allows verification of surgical privileges. You can then print out the verification and it usually shows current status (for example, active or courtesy), the specialty and the dates of association. These template letters do not usually include the specific list of privileges (which is what you want), but the letter serves as verification of the specialty.

Create an aging list on a spreadsheet. It should include everything that has an expiration date, including board certificates if the applicant is younger. Enter expiration dates of certificates and licenses in a calendar that will provide alerts. Tip: Input the date 1 month early to give you time to hassle the doctor for that new license/certificate.

Orderly files
To save embarrassment during your next on-site inspection, review your medical staff bylaws and credentialing policies. While informal changes may have been made to credentialing procedures, what's written rules. You may need to revise policies and bylaws that were written long ago. If you do, make sure that meeting minutes reflect the change. Arrange your files in a uniform manner. Surveyors appreciate not spending time rummaging through piles of paper while looking for the most recent license or certificate. Make the checklist the guide for the order of the file.