Federal regulators are threatening to revoke the University of Maryland Medical System's eligibility to receive payments under the Medicare program, citing lapses in efforts to verify the credentials of doctors in training programs at the Baltimore medical center.
The Health Care Financing Administration's warning follows a state investigation of the medical center's personnel files. The scrutiny began in October after it was discovered that Dr. Arthur B. Boyd Jr., who worked for the system's Shock Trauma Center for two years, was practicing medicine without a license.
The federal regulators have ordered the medical system to submit to what amounts to an extensive audit of its operations. Otherwise, the financing administration can block reimburse- ment for the treatment of Medicare recipients, a significant portion of the center's revenue.
Hospital administrators are appealing the order. They dispute the accuracy of some of the state's findings. They acknowledge that some problems existed but say they have been fixed. And they are challenging the legal basis for the stance taken by the federal officials.
"The hospital's position is that their findings are wrong," said Joel Lee, the system's vice president for communications.
Dr. Boyd, a fellow in surgery at Shock Trauma, was fired Oct. 3 after his bosses investigated and confirmed an anonymous tip that he had never passed his medical licensing exams, despite 15 attempts.
That case prompted Maryland's Licensing and Certification Administration, part of the Department of Health and Mental Hygiene, to conduct a four-day review of the hospital's credential-checking process.
Hospital officials repeatedly have insisted that the case of Dr. Boyd, a 1978 medical school graduate who treated patients for more than two years while enrolled in the fellowship program, was "an isolated incident."
But the state's review turned up a case with some similarities: that of a resident in surgery who, after almost a year of training, was found to lack a medical school diploma.
The unidentified man, Mr. Lee said, completed all of his course work at Ohio State University's medical school but failed to pass his medical licensing exam in his last semester. Ohio State is rare among medical schools, Mr. Lee said, in that it requires medical students to pass that exam before they can graduate.
Medical system officials learned that the surgeon in training did not have an M.D. degree only after someone at Ohio State called in June 1993 and told them, Mr. Lee said. The resident was fired a short time later.
As a result of that incident, Mr. Lee said, the medical system began to consolidate its process for verifying credentials. The changes began in 1993 with new hires and gradually widened to physicians already on staff. Today, Mr. Lee said, the process of reviewing past files is almost complete.
But in October, state regulators found shortcomings.
Files of 23 doctors reviewed
They reviewed the files of Dr. Boyd and 22 other doctors in fellowship or residency programs -- representing a small fraction of the estimated 700 doctors training there. According to that review, recently released by the federal agency:
* In 17 cases, including that of the Ohio State student, there was no confirmation that the medical trainees had graduated from medical school.
* In five cases, including Dr. Boyd's, there was no evidence that the hospital had tried to verify the physicians' claims that they were licensed to practice medicine.
* In 17 cases, including Dr. Boyd's, there was no documentation of claims of professional experience or specialty training.
* In all 23 cases, there was no evidence that the hospital had checked with national databases to see if the doctors had been sued for malpractice.
In a Dec. 20 letter to the federal agency, hospital general counsel Mary Nicholas Humphries pointed out that of the five physicians whose medical licenses hadn't been documented, only one -- Dr. Boyd -- did not actually hold a license.
The prior training of residents, Ms. Humphries wrote, hadn't been verified in only seven cases, not 17. She asserted that graduation from medical school was not verified in nine cases, not 17. And the hospital had not sought information on malpractice suits in 13 cases, not 23.
Mr. Lee said hospital employees had checked credentials in many of the disputed cases but left no paper trail of the effort.
About two or three Maryland hospitals are threatened with the loss of Medicare eligibility in a given year, according to a state health department spokesman.
Medical system administrators expect to sit down with the federal regulators in the next several weeks to argue that the proposed audit would be unnecessary.
Health Secretary Martin P. Wasserman, whose staff conducted the October review, said he supports the hospital's position.
The problem of verifying the credentials of doctors, Dr. Wasserman said, is one that all hospitals face, and further scrutiny of the medical system's procedures would serve little purpose.
University of Maryland Medical Center "continues to deliver good care and has delivered good care, so in that sense that's not at issue here," he said.
Instead, Dr. Wasserman said, he would like to see the state establish a central office responsible for maintaining and verifying the credentials of physicians.
Other problems identified
Regulators also identified some problems outside the medical system's training programs.
Under the bylaws of the university's medical staff, physicians must be "reappointed" to their positions every two years, after performance reviews. But in their October survey, state regulators found six dental surgeons who had continued to practice, without reappointment, for up to 4 1/2 years.
Ms. Humphries, in her letter, said that the medical system "does not dispute that the six oral surgeons should have been reappointed."
She blamed the system's failure to do so on a dispute between the hospital's departments of dentistry and surgery.
The dispute, she wrote, stemmed from the chairman of surgery's demand for the right to approve certain procedures by dental surgeons.