Current through Register Vol. 51, No. 19, September 20, 2024
A. Qualifications
of Physicians and Staff. A facility shall ensure that all physicians and other
health professionals who are employees or contractual staff have been
appropriately trained and licensed or certified under the Health Occupations
Article, Annotated Code of Maryland.
B. Credentialing of Physicians. The facility
shall collect, review, and document the following information concerning a
physician licensed under Health Occupations Article, Title 14, Annotated Code
of Maryland:
(1) The physician's
education;
(2) The professional
experience of the physician, including:
(a)
Any board certification or specialty training of the physician; and
(b) Any post-graduate training;
(3) Any license or registration to
practice a health occupation ever held by the physician, including DEA
registration;
(4) Any hospital
where the physician was appointed or employed during the last 10 years,
including:
(a) The name of the
hospital;
(b) The term of
appointment or employment; and
(c)
Privileges held and any disciplinary action taken, including suspension,
revocation, limitation, or voluntary surrender;
(5) The physician's professional liability
insurance for the last 5 years, including:
(a) The physician's present
carrier;
(b) The physician's
current limits of coverage;
(c) The
physician's current types of coverage; and
(d) Restrictions on the physician's
coverage;
(6) Any claim
that has been made against the physician in the practice of a health occupation
in the last 5 years, and the status of the claim;
(7) Any physical or mental condition that
currently impairs the physician's ability to exercise privileges;
(8) Any complaint or report, permitted to be
disclosed by law, which has been filed with any state licensing or disciplinary
body, or comparable body of the armed forces; and
(9) Data provided by the National
Practitioner Data Bank.
C. For a physician who has privileges in a
licensed Maryland hospital, the administrator may verify, through the hospital,
the credentials described in §B of this regulation.
D. The administrator shall establish a
procedure for the biennial reappointment of a physician which includes:
(1) An update of the information required in
§B of this regulation; and
(2)
An assessment of the physician's performance pattern based on an analysis of:
(a) Complaints filed with the
facility;
(b) Malpractice claims
filed;
(c) Utilization, quality,
and risk data;
(d) Adherence to
policies, bylaws, and procedures; and
(e) Physician practice patterns as reviewed
through the facility's quality assurance program.
E. Credentialing of Health
Professionals.
(1) Direct Hires.
(a) The facility shall collect, review, and
verify evidence of the following information for all licensed or certified
health professionals that are employed by the facility:
(i) A current license or certificate to
practice in this State; and
(ii)
Malpractice insurance, if required by the facility.
(b) The administrator shall approve the
delineation of services to be provided by the health professional.
(2) Nondirect Hires. When a
licensed physician uses a health professional to provide services at the
facility, and that person is not employed by the facility, the licensed
physician who employs the health professional is responsible for verifying the
information required in §E(1) of this regulation.
