2% of Health Practitioners Are Not Licensed; 19% Have Issues with Credentials

Cheryl Clark, for HealthLeaders Media , October 9, 2009

Nearly 2% of health providers, including 1.6% of physicians and osteopaths, are practicing without a license and 18.7% have some cloud on their credentials, according to a new report from a company that checks licensing, credentialing, and malpractice litigation history.

The survey, published by Medversant of Los Angeles, used a patented tracking system to provide background checks on nearly 30,000 health practitioners for clients, such as state governments, hospitals, health plans, and nursing registries.

Matthew Haddad, president and CEO of Medversant, says the finding of so many practitioners who shouldn't be practicing is alarming, and points to a potential for widespread fraud.

"What's often the case is that when you have a provider billing who is not licensed, very often that patient is fictitious," he says. He adds that many state and federal agencies are interested in the finding in an effort to prevent paying bogus claims as well as safeguard quality of care.

The Medversant system checks for daily updates on licensees, which Haddad says is a vast improvement over the routine practice of checking once every two to three years, a requirement from The Joint Commission, healthcare accrediting organizations, government regulatory agencies, and the Center for Medicare and Medicaid Services.

The survey also revealed:

  • Adverse findings were found in 20.4% of 20,243 physicians, 13.5% of 208 dentists, 25.8% of 585 podiatrists, 6.4% of chiropractors, 11.3% of 646 physician assistants, 9% of 1,621 nurse practitioners, and 8.7% of 5,475 allied health professionals.

  • Expired, cancelled, delinquent, inactive, lapsed, not renewed, not registered, null and void, revoked, suspended, surrendered, terminated or voluntarily surrendered licenses were discovered among 5.1% of physicians assistants, 2.8% of nurse practitioners, 2.7% of allied health professionals, 2% of podiatrists, 1.6% of physicians and osteopaths, 1.4% of dentists, and .7 % of chiropractors.

  • Among the 29,845 practitioners reviewed, 80 were either deceased or retired. "These practitioners, at the time of license verification, were listed in one or more health plan provider directories as a participating provider."

The company is marketing its services in an effort to help payers guarantee quality of care.

It checks the Educational Commission for Foreign Medical Graduates, specialty board certifications, licensing agencies, the Drug Enforcement Administration, state controlled drug and substance agencies, professional liability coverage listings and claims history, the National Practitioner Data Bank, healthcare facility affiliations, employment, peer references, and history of failure to disclose adverse actions.

For example, a state government might wish to know whether a Medicaid provider who files a reimbursement claim is licensed to provide the service. A hospital may wish to validate the disciplinary peer review history of a physician seeking staff privileges. And a health plan may wish to expand its network to providers within a certain network.

"The consequences to an organization that employs or uses services from an unlicensed physician can be extreme," Haddad says, even if the license is merely overdue for renewal.

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