Are Pre-Applications Necessary to Include in the Privileging Process?

A Little History Related to Pre-Applications

Medical Staff Professionals were advised by hospital attorneys years ago (in the early to mid-80’s) that costly, time-consuming hearings could be avoided by developing and utilizing a pre-application process. The theory was that potential applicants should be informed “up front” what qualifications must be met to receive an application for membership and/or privileges, and therefore be considered an “applicant.” The pre-application was a screening process for a provider requesting an application for Medical Staff membership. It was utilized to assure the hospital and medical staff that the potential applicant met the basic minimum criteria for membership (at this point in time, there wasn’t much privileging criteria). In other words, it was felt to be a waste of time both for the applicant and hospital, for an application to be accepted by a hospital when the provider did not meet minimum criteria for membership. And – if an application was accepted, the conventional wisdom was that the application had to be processed, and denied if the applicant didn’t meet the organization’s criteria. If the submission of an application resulted in a denial, the affected provider would be entitled to the fair hearing procedures described in the medical staff bylaws.

In a pre-application process, the applicant is required to provide information in order to demonstrate that they meet the minimum criteria for membership and to receive an application. Often this information is then again requested as part of the application.

Today’s Environment

We now know that organizations are not required to process an application from any applicant who does not meet organization requirements, and often there are important issues which surface during the verification process which require an explanation of additional information in order to continue processing an application.

Another reason that organizations have eliminated this process or are taking a second look at the pre-application process is that it can often add days to weeks to the time frame that it takes for a new applicant to obtain membership or privileges. The pre-application must be completed and returned and if the applicant meets criteria, then an application is provided. This process has proven to be another source of frustration for a new applicant who already feels that the credentialing process is burdensome, duplicative and time-consuming. Many organizations have streamlined the process by providing the applicant with clearly stated information outlining the minimum criteria for membership at the time the application is provided. Still other organizations have included the criteria at the beginning of the application, with instructions to “stop and do not continue” completing the application if the applicant does not meet criteria. Organizations have gotten much better in recent years (since the introduction of reporting requirements to the National Practitioner Data Bank) of identifying and documenting requirements for membership. CMS and Joint Commission accreditation requirements are prompting many organizations to also refine and clearly state requirements for privileges.

Some organizations have established methods to determine whether or not a provider will be sent an application. Some of these methods appear – from a provider’s point of view – to be analogous to getting invited to join an exclusive club. Others are related to some type of “medical manpower plan” where an organization determines in advance the types and numbers of specialists that are needed to provide services to the patient population. I once did a credentialing evaluation at a well-regarded orthopedic hospital and they had over 50 dermatologists on staff. The hospital certainly didn’t need that many dermatologists, but there was prestige in having an affiliation with this hospital printed on business cards. The medical staff office was having significant problems keeping up with the credentialing because of the extraneous applications that were being accepted and processed. This is a case where a medical manpower plan makes sense! But most hospitals do not have these types of formal plans. In fact, we are now in a situation where many hospitals are seeking applicants.

Let’s say an organization recruits a physician. This is typically a lengthy process, involving lots of back and forth communication and interviews with high-level organization representatives, reference checks, salary and contract negotiation, etc. A contract is extended to the recruited physician. The medical staff office is notified of the need to credential the physician. And – the first thing that is sent to the recruited physician is – you guessed it – a pre-application! This practice makes the credentialing part of the provider’s recruitment feel disconnected, extraneous, and duplicative.

Even though we believe that a pre-application is unnecessary – we know that there is information that has to be gathered in order to provide the appropriate application packet to a new application. This information can be gathered via an “application request.” The application request form may be available on an organization’s website and submitted electronically, it could be emailed to a provider for completion or it could be completed on behalf of the provider by recruitment or an individual in the medical staff office. The type of information that is needed is name and other data elements necessary to initiate the application, the applicant’s specialty, types of privileges needed, facilities where the applicant will need to be privileged and locations where the applicant will be working. It is also important to allow the applicant to provide a credentialing contact/delegate who will assist with completion of the application. Many organizations ask for the projected start date. It is clear that this information could best be provided by the individual/department responsible for recruitment of the provider if applicable.

Establishing expectations upfront with new applicants is always wise, and it is important to use every opportunity to communicate with a candidate so that they will fully understand the credentialing process and related requirements.

Elimination of the pre-application process does not eliminate the necessity for applicants to prove that they meet all organization requirements for membership and/or privileges.

We now know that processing of an application can be stopped any time it becomes evident that an applicant does not meet organization requirements. And – we also know that when an applicant does not meet organization requirements, it is not a denial of membership or privileges. It is a matter of the applicant not meeting “threshold eligibility requirements” and therefore no fair hearing process is applicable.