Did you know it is not an accreditation requirement or CMS Conditions of Participation to screen the medical staff for criminal or credit history? Although many consultants and surveyors recommend the medical staff office screen applicants for criminal and credit histories, this is based on a personal preference or bias and not on any accreditation standard. There are limited circumstances where checks are required by state law, but those laws are narrowly defined and often affect employees and not members of the hospital or surgery center medical staff.

Not only are these checks voluntary in most cases but their scope and implementation should be carefully drawn. Borrowing from the American Medical Association’s Physician’s Guide to Medical Staff Organization Bylaws (Fourth Edition):

“Some consulting firms and security agencies promote “passing” criminal background and even credit checks as a requirement for medical staff membership. Obtaining meaningful criminal background information would necessitate verification with federal and every state’s criminal justice systems, and may or may not be required under state law. Approximately half of the states’ licensing agencies have authority to conduct a criminal background check as part of the medical licensing process, and some licensing agencies are required to carry out criminal background checks, making the process at the medical staff level in those states redundant.”

Neither the Joint Commission nor AAAHC standards require medical staffs to establish criminal or credit background requirements. NCQA does not require background checks as part of the credentialing process for provider panels. As a result, there are no standards for how background checks of this sort should be conducted. If you do perform checks, great care should be taken to comply with both federal state law regarding notice and disclosure to the investigated person of information derived from background checks. For example, see the federal Fair Credit Reporting Act, which requires obtaining the written consent of an applicant before obtaining credit history and disclosure to the applicant if an adverse decision is made based in whole or in part on a credit report.

The Federation of State Medical Boards (FSMB) provides a summary of state law and pending legislation addressing background checks by state medical licensing boards. You may view this summary of state laws at the FSMB site: www.fsmb.org/pdf/grpol_criminal_background_checks.pdf.

If you use a background search service, you are well-advised to look at what you are actually purchasing and whether the company is following the fair credit reporting laws as applicable. Your organization may be required to fulfill the FCRA as well as possible state law that further protects consumers.  For example, you may need to notify the applicant about negative information revealed by a background check and provide him or her the opportunity to contest the information.  Also, be prepared to outline your decision making through a policy that addresses what happens if negative information arises from a credit or criminal background check.  For example, consider defining what negative information poses a potential threat to patient care or safety or other justifiable basis for disciplinary action.  Consider this fact -- if you take a formal action based on a negative report, you could end up in court explaining your actions.


March 18, 2010