Veterans Health Administration: Greater Focus on Credentialing Needed to Prevent Disqualified Providers from Delivering Patient Care
The Veterans Health Administration’s credentialing process ensures that the doctors and other health care providers it hires are qualified. The process includes a check on whether a provider has been disciplined by a licensing board.
We found VHA hired or retained ineligible providers in some cases because hiring staff:
Overlooked or missed disqualifying information in a national database
Didn't know that providers with valid licenses were ineligible if they had surrendered a license or had one revoked in another state
We made 7 recommendations, including more training for VHA staff who review credentials and hire providers.
VA medical center.
What GAO Found
GAO found that Veterans Health Administration (VHA) facilities responded in various ways to adverse-action information from the National Practitioner Data Bank (NPDB) for the 57 providers reviewed, and in some cases overlooked or were not aware of adverse action.
In some cases, providers had administrative or other nondisqualifying adverse actions reported in the NPDB, but VHA facilities determined they could be hired. For example, VHA hired a physician who had surrendered his physical-therapy license for not completing physical-therapy continuing education. Although his license surrender resulted in an adverse action in NPDB, VHA determined that there were no concerns about the provider's ability to perform as a physician.
VHA facilities disciplined or removed providers when they learned about adverse actions reported in NPDB. In addition, after GAO raised questions about certain providers' eligibility, based on GAO's examination of adverse-action information, VHA facilities removed five providers that it determined did not meet licensure requirements.
In some instances, VHA facilities overlooked or were unaware of the disqualifying adverse-action information in NPDB. In these cases, VHA facilities inappropriately hired providers, but some providers were no longer working at VHA at the time of GAO's review. For example, VHA officials told GAO that in one case, they inadvertently overlooked a disqualifying adverse action and hired a nurse whose license had been revoked for patient neglect. This nurse resigned in May 2017.
VHA facilities did not consistently adhere to policies regarding providers with adverse actions. Among other issues, GAO found that some facility officials were not aware of VHA employment policies. Specifically, GAO found that officials in at least five facilities who were involved in verifying providers' credentials and hiring them were unaware of the policy regarding hiring a provider whose license has been revoked or surrendered for professional misconduct or incompetence, or for providing substandard care. As a result, these five VHA facilities hired or retained some providers who were ineligible. VHA provides mandatory onetime training for certain VHA staff, but not for staff responsible for credentialing. The absence of periodic mandatory training may result in facility officials who are involved in credentialing and hiring not understanding the policies and hiring potentially ineligible providers.
VHA officials described steps they have taken to better ensure that providers meet licensure requirements. For example, VHA completed a onetime review of all licensed providers beginning in December 2017 and removed 11 providers who did not meet the licensure requirements as a result of this review. VHA officials said these types of reviews are not routinely conducted, and noted the review was labor intensive. Without periodically reviewing those providers who have an adverse action reported in NPDB, VHA may be missing an opportunity to better ensure that facilities do not hire or retain providers who do not meet the licensure requirements.
Why GAO Did This Study
VHA provides health services to almost 9 million veterans at medical facilities nationwide. Through the credentialing process, VHA facilities determine whether providers have the appropriate professional qualifications to provide care. The NPDB is one information source VHA uses to determine whether providers have been disciplined by a state licensing board or a health-care facility. Such discipline results in “adverse actions,” that may disqualify providers from practicing at VHA.
GAO was asked to review how allegations of provider misconduct are resolved. GAO examined (1) how officials at VHA facilities responded to adverse-action information received through NPDB, (2) how VHA facilities adhered to polices regarding providers with adverse actions, and (3) steps VHA has recently taken to ensure that providers meet licensure requirements. GAO analyzed a nonprobability sample of 57 health-care providers—including physicians, nurses, and dentists—working at VHA as of September 2016 who had an NPDB record. GAO considered factors such as the seriousness of the offense reported to NPDB. GAO reviewed state licensing-board documents. GAO also examined VHA policies, and interviewed VHA officials.
GAO is making seven recommendations, including that VHA ensure that facility officials responsible for credentialing and hiring receive periodic mandatory training, and periodically review providers who have an adverse action reported in NPDB. The agency concurred with GAO's recommendations.
Recommendations for Executive Action
|Department of Veterans Affairs||The Under Secretary for Health should ensure that facility officials who are responsible for credentialing, reviewing credentials, and hiring receive periodic mandatory training. (Recommendation 1)||
As part of our review of the Veterans Health Administration (VHA) credentialing processes, we found that VHA facilities did not consistently adhere to policies regarding providers with adverse actions. Credentialing refers to the process of screening and evaluating qualifications and other credentials-including licensure, education, and relevant training-which is the first step in the process of determining whether the provider has appropriate clinical abilities and qualifications to provide medical services. Once the provider submits his or her required credentialing information, a facility employee-usually the credentialer-collects documentation from the original source for each credential, in order to confirm the factual accuracy of the information. For example, the credentialer would typically contact educational institutions to confirm dates of participation and program completion. This is referred to as primary-source verification. The credentials file contains information that the credentialer primary-source verified, including the provider's licensure status, any adverse actions reported to the National Practitioner Data Bank, education, and experience. Facilities generally have committees responsible for reviewing provider credentials, and the facility Director has the ultimate responsibility for ensuring that the facility adheres to VHA's credentialing policies. Among other issues, we found that some facility officials were not aware of VHA employment policies. Specifically, we found that officials in at least five facilities who were involved in verifying providers' credentials and hiring them were unaware of the policy regarding hiring a provider whose license has been revoked or surrendered for professional misconduct or incompetence, or for providing substandard care. As a result, these five VHA facilities hired or retained some providers who were ineligible. VHA provides mandatory onetime credentialing training for certain VHA staff, but not for staff responsible for verifying credentials (i.e., credentialers). According to VHA policies there is a onetime, mandatory training for officials reviewing credentials and making hiring decisions specifically, service chiefs, facility Directors, and credentialing committees. No mandatory training was required for credentialers. The absence of periodic mandatory training may have resulted in facility officials who are involved in credentialing and hiring not understanding the policies and hiring potentially ineligible providers. In February 2019, we recommended that the Under Secretary for Health should ensure that facility officials who are responsible for credentialing, reviewing credentials, and hiring receive periodic mandatory training. In November 2020, the Department of Veterans Affairs (VA) told us and provided documentation that VHA staff responsible for credentialing and privileging are now required to complete training on an annual basis. The training discusses actions that credentialers must take when they become aware of licensure, registration, or certification issues. By doing this, VA has taken action to ensure that credentialing staff and officials responsible for reviewing credentials and making hiring decisions will be able to accurately identify providers who do not meet eligibility requirements.
|Department of Veterans Affairs||
Priority Rec.The Under Secretary for Health should develop policies and guidance regarding DEA registrations, including the circumstances in which Drug Enforcement Administration (DEA) waivers may be required, the process for requesting them, and a mechanism to ensure that facilities follow these policies. (Recommendation 2)
As of January 2023, this recommendation remains open. VA sent a letter to DEA asking for clarification about DEA employment waivers and received a response from DEA dated November 26, 2019. VA officials told us that they are considering the input from DEA and consulting with relevant stakeholders to determine next steps. In December 2021, VA said that an Interdisciplinary Project Team is working towards identifying the best approach to management and oversight of DEA waivers. In March 2022, VA told us that this work is ongoing. In January 2023, VA told us that the Interdisciplinary Project Team's proposal is under review within VHA and that the target completion date is June 2023. To fully implement this recommendation, VA needs to provide evidence of actions taken to ensure that DEA requirements regarding DEA registrations and employment waivers are met. Such actions include developing policies regarding when a DEA employment waiver may be necessary and guidance about how to request such a waiver.
|Department of Veterans Affairs||
Priority Rec.The Under Secretary for Health should identify and review providers whose DEA registrations were revoked or surrendered for cause and determine whether an employment waiver may be needed from DEA. (Recommendation 3)
In March 2020, VA officials told us that they used the National Practitioner Data Bank (NPDB) to review licensed independent practitioners to see if any providers that are currently employed at VA have a revoked or surrendered DEA registration. They identified at least one provider with a revoked or surrendered DEA registration. In November 2020, VA officials told us that VHA General Counsel reviewed the provider's case and determined that a DEA waiver is not necessary because the provider does not handle or prescribe controlled substances. By doing this, VA has taken action to ensure that no licensed independent practitioners employed at VA require a DEA waiver.
|Department of Veterans Affairs||The Under Secretary for Health should confirm that Veterans Integrated Service Network (VISN) VISN-level Chief Medical Officer reviews are being appropriately documented so that VHA Central Office officials are able to ensure that facilities and VISNs are complying with oversight policies. (Recommendation 4)||
In August 2019, the Department of Veterans Affairs (VA) told us, and provided documentation, that it had added a feature in December 2018 to its web-based credentialing system, VetPro, so that reviews completed by VISN Chief Medical Officers (CMO) can be identified and distinguished from reviews conducted by facility service chiefs. By doing this, VA has taken action to ensure that CMO reviews are documented and enable VHA Central Office officials are able to monitor facilities' and VISNs' compliance with oversight policies.
|Department of Veterans Affairs||The Under Secretary for Health should confirm that the appropriate VHA Central Office is conducting monitoring to ensure that required VISN-level Chief Medical Officer reviews of licensed independent practitioner credentialing files are conducted. (Recommendation 5)||
Our report recommended that the Under Secretary for Health should confirm that the appropriate VHA Central Office is conducting monitoring to ensure that required VISN-level Chief Medical Officer reviews of licensed independent practitioner credentialing files are conducted. In August 2019, the Department of Veterans Affairs (VA) told us that VHA redesigned the tracking system utilized for reviews of the National Practitioner Data Bank (NPDB) Continuous Query disclosures for licensed independent practitioners and that VHA's Medical Staff Affairs verifies that required Chief Medical Officer reviews are completed. In March 2020, VA provided a screenshot of the tracking tool that Medical Staff Affairs uses to ensure that required Chief Medical Officer reviews are completed. By doing this, VA has taken action to ensure that required VISN Chief Medical Officer reviews occur, providing greater assurance that providers serving veterans have been subject to timely, appropriate credentialing.
|Department of Veterans Affairs||The Under Secretary for Health should direct the VHA facilities to periodically review provider licenses using NPDB adverse-action reports, similar to recent VHA-wide reviews. Facility officials should take appropriate action on providers who do not meet the licensure requirements, and report the findings to VHA VISN and Central Office officials for review. (Recommendation 6)||
Our report recommended that the Under Secretary for Health should direct Veterans Health Administration (VHA) facilities to periodically review provider licenses using the National Practitioner Data Bank (NPDB) adverse-action reports. The Department of Veterans Affairs (VA) told us that it agrees with reviewing provider licensure actions and taking appropriate administrative actions. However, because VHA reviews just-in-time alerts from the NPDB continuous query program, it viewed retrospective review of NPDB adverse action reports as less timely compared to using NPDB continuous query alerts. NPDB continuous query automatically alerts VHA when one of its enrolled health care providers has a new NPDB report. At the time we made the recommendation, dependent providers were not enrolled in NPDB continuous query. In December 2019, the Deputy Under Secretary for Health for Operations and Management issued a memorandum that requires VHA facilities to enroll all licensed providers-including dependent providers-in NPDB continuous query by March 30, 2020. VA provided a screenshot of VetPro, VHA's credentialing system, which indicates that as of February 18, 2020, nearly 67,000 of the approximately 112,000 dependent providers were enrolled in NPDB continuous query. If NPDB continuous query reports are timely and appropriately reviewed, VHA will be able to identify health care providers who no longer meet licensure qualifications without having to conduct retrospective reviews.
|Department of Veterans Affairs||The Under Secretary for Health should direct the Office of Quality, Safety and Value (QSV) to compile and disseminate to all facilities best practices employed by facilities that have proactively identified and addressed provider adverse-action licensure issues. (Recommendation 7)||
Our report recommended that VHA look across its facilities and bring together best practices associated with reviewing credentials and disseminate those practices to improve the credentialing process. Rather than looking to facilities to continuously refine the credentialing process through best practices, VHA took steps to improve and standardize the process, disseminate the new process across the VHA, and discourage facilities from developing alternative processes. Specifically, in August 2019, VA said that Medical Staff Affairs (MSA), which is under VHA's Office of Quality, Safety, and Value (QSV), and is responsible for credentialing and privileging has standardized practice and procedure. The codified expectations are an effort to better minimize variation and ultimately risk. VHA believes the previous lack of standardization of the review process resulted in varying interpretation of review requirements. It added that VHA continues to move forward in eliminating variance and discouraging facilities to drift from the requirements by establishing local procedures. Specifically, in January 2019, VHA's Deputy Under Secretary for Health for Operations and Management implemented a more robust process that ensures appointed providers continue to meet licensure qualification requirements if a licensure action has been taken. The review must be documented on a standardized form and filed in the provider's VHA electronic credentialing record. In our report we noted that officials from a facility that had taken actions to identify employees who do not meet licensure requirement, or to improve the credentialing process, described updating their standard operating procedures to require licensure actions be elevated to management, such as the Human Resource Officer, for review and sign-off. In September 2019, a QSV official noted that Human Resource Officers are now required to sign off on all providers with an adverse action on his or her license. Further, according to VHA, additional reference materials have been developed for credentialers on the process for VHA's unique requirement to enroll licensed independent providers in the NPDB Continuous Query program. This requirement allows VHA to proactively identify licensure actions and is a best practice in the health care industry. Finally, MSA prepared a two-part training course for credentialers on the NPDB Continuous Query process and managing NPDB alerts.