RCM&D Corporate Blog

Great Pretenders: The Implications are Endless

Posted on: Mon, 23 Mar 2015

Here’s a question… with all of the information accessible through the internet and other avenues, just how easy is it for one person to assume another person’s identity?  If we could ask Shawna Gunter of Severna Park, Maryland, she would probably tell us that it’s fairly simple.  Gunter provided a forged diploma, physician assistant certification, state license and DEA certification to a pediatric practice where she was hired as a physician assistant on July 5, 2013.  Gunter treated patients for almost two months until the owner of the practice received information that indicated Gunter was not qualified as a physician assistant and contacted the Maryland State Police.

In all models of healthcare delivery, it is imperative to know the identities of those who are providing care to patients.  How do we know that a physician, physician assistant, nurse practitioner or other provider has the credentials that they claim to hold?

It should be fairly simple to identify applicants who are lying about their identities or credentials, and it can be, with a sound system for proper verification.  In order to maintain accreditation, hospitals and health systems are required to verify the information submitted on an application for privileges.  If a practice is owned by a hospital or health system, accreditation may be inherent.  Few medical practices will seek accreditation that would obligate them to establish and conduct a credentialing verification process.  While medical practices that are not accredited might not perform verifications during the hiring process, is lack of such confirmation safe for patients, and is it a good business practice?

Consider the impact of hiring an unlicensed, unqualified individual to provide care to the patients in your practice.  In the above-mentioned case, simple license verification might have been enough to identify Gunter as a potential imposter.  Verification of her professional education would surely have exposed the misrepresentation.  The absence of a thorough review of candidates elevates the risk for patient harm, exposure to liability suits, HIPAA violations, potential submissions of false claims to Medicare and Medicaid, and a tarnished reputation.

However, a good review process is not always enough to protect your practice or organization from phonies.  In January of this year, in West Palm Beach, Florida, a teenager in a lab coat was caught roaming the halls of St. Mary’s Medical Center.  According to an article published by The Guardian, the hospital released a statement which said the teen “never had any contact with any hospital patients and did not gain access to any patient care areas of the hospital at any time.”  However, some accounts of the incident placed the teen in highly sensitive, private areas.  According to one physician, “He presented himself with a patient of our practice and introduced himself as Dr. Robinson.”   The teen was reportedly discovered after being caught in an examination room with a patient.  Regardless, the thought is scary, isn’t it?

This situation presents additional security threats.  If an individual just walks in proclaiming to be someone that they are not, who would be there to stop them?  This situation calls for stepped-up human diligence, as well as strengthened security protocols and orientation processes.

I often hear concerns from physicians and administrators about the length of time that is required to complete the credentialing process.  Yes, the process can be lengthy and cumbersome, but it is necessary.  A comprehensive and thorough process is essential.  There will always be people who will use many different methods to defraud the healthcare system, some seeking personal gain or acting with criminal intent, others may be suffering from mental illness.  One thing is for certain, it happens!  Are you protected? Are you doing everything you can to protect your patients, your practice and your organization?

If you would like more information about how RCM&D can help assess your credentialing risk, contact Dorathy Pingel at dpingel@rcmd.com or via LinkedIn.