How do malpractice claims or disciplinary actions affect credentialing?

Malpractice or disciplinary history must be disclosed and verified when required, then reviewed under the payer or organization’s credentialing policies.

Adverse history does not automatically produce the same outcome in every case. The impact depends on the nature, timing, frequency, current license status, payer policy, and the organization’s review process. Credentialing staff should make sure required disclosures are complete and consistent with primary-source findings, then route the information through the proper review process.

• Adverse history must be disclosed when required.
• Verification is important.
• One event does not automatically mean denial.
• Policies determine how the matter is reviewed.

A physician discloses a prior malpractice claim. The credentialing specialist obtains the required information and sends the complete file through the organization’s review process.

• Hiding adverse history.
• Assuming any malpractice claim automatically disqualifies a provider.
• Ignoring discrepancies.

Emphasize disclosure, verification, and policy-based review.