Medical Credentialing Actions

Medical providers operating within the Department of Defense can find their ability to practice medicine in jeopardy following the initiation of the Clinical Adverse Action process. The process is invoked against a health care provider after concerns are raised regarding the provider’s practice.

An Overview of the Adverse Clinical Action Process

The beginning stages of the adverse clinical action process are marked by the initiation of a Quality Assurance Investigation (QAI), which is supposed to be an impartial investigation by a peer with a similar background and experience to that of the provider under investigation. The action is typically initiated when a provider is accused of incompetence, malpractice, or shows signs of impairment.

Once the investigation is completed, the provider is given a copy of the report and afforded an opportunity to respond and contest any recommendations made by the Investigating Officer. These recommendations can range from a denial, restriction, reduction, or revocation of all privileges held by the provider.

The Credentials Committee then reviews the QAI report and the statement from the provider under investigation before making a recommendation to the Medical Treatment Facility Commander. The Commander will then issue a decision and the provider will be afforded an opportunity to appear before a panel of impartial peers. This panel is composed of peers with similar background and experience as the provider under investigation.

The hearing process is the provider’s opportunity to contest the decision of the MTF Commander before a panel of his/her peers. The hearing process is adversarial in nature. The MTF will assign a representative to present the MTF’s case. These representatives often call witnesses who have an adverse opinion of the provider under investigation. Panel members can ask questions of the MTF witnesses and often do so in their pursuit of the facts needed to make a decision.

If the Panel makes an adverse recommendation, the Privileging Authority often follows that recommendation, but not always. If revocation or restriction of privileges is recommended, the provider and the associated report with be referred to the National Practitioner’s Data Bank.

This repository is required to collect and report information on providers who have been professionally disciplined by a state licensing board or health care entity. The NPDB is searched before a provider is hired by an entity’s medical staff and when renewal of privileges is necessary. A provider who has been reported to the NPDB can expect to encounter significant prejudice in their career following a report to the NPDB.

Providers facing a QAI or exercising their due process rights must not assume that a QAIO or Peer Review Panel will make a recommendation in their favor. Rather, they should be prepared to contest the evidence and testimony that will be presented against them. Any provider facing a QAI or electing to appear before a Peer Review Panel should consult with experienced counsel who can ensure the provider’s rights are not infringed upon and that the appropriate legal and health care standards are being applied.

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