PSV is More Than a Checkbox: The Rural Health Executive’s Guide to Primary Source Verification
For rural hospital executives, Primary Source Verification (PSV) is often viewed as a simple checklist item for the credentialing team. This perspective carries significant financial risk. Done incorrectly, PSV exposes your organization to compliance penalties, claim clawbacks from CMS, and crippling liability for negligent credentialing.
Understanding what is legally required versus what is mandatory for liability protection is a crucial distinction every CEO and CFO must grasp.
What is PSV, and Why Must It Be The Gold Standard?
PSV is the act of verifying a provider’s credentials directly from the original source—the entity that issued the document. For a physician’s state license, this means going to your state’s medical board, such as the Texas Medical Board (TMB) website, not simply accepting a photocopy from the provider. PSV proves to auditors, payers, and courts that your hospital performed rigorous due diligence before granting privileges.
4 Non-Negotiables: The “Must Do” Legal Requirements
For any provider seeking privileges or employment at your Critical Access Hospital (CAH) or Rural Health Clinics (RHCs), these four items are legally mandated by state or federal law.
1. Clinical Licensure (The Legal Foundation)
The state license is the primary proof that a provider is legally qualified to practice.
The Requirement: Current, active license to practice in Texas, verified directly on the state board’s website (e.g., Texas Board of Nursing, TMB). The TMB website results are the “Gold Standard” of PSV.
Executive Action:
Mandate that verification of clinical licenses must be performed at initial hire and before every license expiration. Do not accept provider photocopies as definitive proof.
2. Federal and State Sanction Checks (The Financial Risk)
If you bill Medicare or Medicaid for services provided by an excluded individual, the hospital can face massive fines and the mandated clawback of payments.
The Requirement: Check that the provider is not on mandatory exclusion lists.
Key Lists to Check:
- OIG LEIE: (Office of Inspector General List of Excluded Individuals/Entities)
- SAM.gov: (Federal System for Award Management)
- Texas Medicaid Exclusion List
Executive Action:
Implement an automated system to check the OIG/SAM lists at hire and monthly thereafter. Quarterly or annual checks are too risky for sustained compliance.
3. Drug Enforcement Agency (DEA) Registration
Any provider prescribing controlled substances must have a current DEA registration.
The Requirement: Current DEA registration, verified through the NTIS or DOJ website.
Executive Action:
Ensure DEA registration is tracked as a primary expiring document and is verified before the provider is added to the medical staff.
4. Identity Verification
You must confirm the individual is who they claim to be.
The Requirement: View a government-issued photo ID (Driver’s License/Passport).
Executive Action:
Establish a firm policy to document the viewing of a government ID (including the ID number and date viewed). Crucially, prohibit keeping photocopies of the Driver’s License in the permanent file to mitigate identity theft risk and maintain data security best practices.
The “Diploma Dilemma”: The True Liability Risk
Many executives ask why they need to verify training and education if the state licensing board has already done so. This is the difference between minimum compliance and liability protection.
The Risk: While the license meets the letter of CMS law, almost all hospital medical staff bylaws and accrediting bodies (like The Joint Commission or DNV) require verification of medical school, residency, and fellowship. If a provider is involved in a malpractice suit and it is discovered they falsified their residency—even with a valid license—your hospital can be held liable for negligent credentialing.
Executive Action:
Treat medical school, residency, and fellowship verification as Required for all privileged staff (MD/DO, NP, PA) to meet the community standard of care and protect the hospital’s corporate liability shield.
Special Note for Rural Clinics (RHCs)
Do not assume your hospital’s credentialing process automatically covers your Rural Health Clinics. RHCs must maintain their own proof of credentialing files on-site (or easily accessible) that demonstrate compliance with 42 CFR Part 491 (Federal RHC regulations). The credentialing and privileging infrastructure for your RHCs must be as robust as the hospital’s.
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