Problem-Specific Guide
The Reality of Malpractice Claims
Malpractice claims are a reality of medical practice. Studies suggest that a majority of physicians in certain specialties will face at least one malpractice claim during their career. Having a claim—or even multiple claims—doesn't end your career. But it does complicate credentialing.
Every credentialing application asks about malpractice history. Your answers, how you document them, and how you explain them significantly affect credentialing outcomes.
Understanding What's Asked
Application Questions
Credentialing applications typically ask about:
- Pending malpractice claims
- Claims filed in the past 5-10 years (varies by application)
- Settlements (regardless of fault admission)
- Judgments against you
- Claims closed without payment
What "Claim" Means
Applications may use different terminology:
- Lawsuit: Formal legal action filed in court
- Claim: Demand for compensation (may or may not be lawsuit)
- Settlement: Payment to resolve claim (may not admit fault)
- Judgment: Court decision after trial
Read questions carefully—they may ask about claims even if no lawsuit was filed.
Look-Back Periods
Different applications have different time frames:
- State licenses: Often 5-10 years, some ask "ever"
- Hospital privileges: Typically 5-10 years
- Payer enrollment: Varies, often 5 years
- NPDB: Reports remain indefinitely
The NPDB Factor
What Gets Reported
The National Practitioner Data Bank receives reports of:
- Malpractice payments (any amount, regardless of fault)
- State licensure actions
- Hospital privilege actions
- Professional society actions
- DEA actions
NPDB Access
Who queries the NPDB:
- Hospitals (required before granting privileges)
- State medical boards (most query)
- Health plans (increasing use)
- You (self-query available)
Why NPDB Matters
If a settlement was made on your behalf, it's in the NPDB. Credentialing organizations will see it. Failure to disclose what's in your NPDB report looks like dishonesty.
Self-Query Your NPDB
Why Self-Query
Before any credentialing application:
- Request your own NPDB report
- Know exactly what's reported
- Ensure your disclosures match
- Identify any errors to dispute
How to Self-Query
- Visit NPDB website
- Create account or log in
- Request self-query (currently $4.25)
- Receive report showing all reports about you
Disclosing Malpractice History
The Cardinal Rule: Disclose
When applications ask about malpractice history, disclose. Always. Completely.
- Non-disclosure of reportable events is often worse than the event itself
- It suggests dishonesty or lack of awareness
- It will be discovered (NPDB, court records, prior applications)
- It can be grounds for denial or revocation
What to Include
For each reportable event:
- Date of incident
- Date claim was filed
- Date of resolution
- Type of resolution (settlement, dismissal, judgment)
- Amount (if settlement or judgment)
- Brief description of the case
- Your role in the care
The Explanation Statement
Most applications allow you to explain the circumstances. Use this opportunity wisely:
- Be factual: State what happened objectively
- Be concise: One paragraph is usually sufficient
- Don't be defensive: Avoid blaming others or sounding bitter
- Show insight: If applicable, what did you learn?
- Note the outcome: Dismissed, settled without admission of fault, etc.
Writing the Explanation
Structure
An effective explanation typically includes:
- Brief clinical context
- What happened
- The claim and its resolution
- Perspective (if helpful)
Example Framework
"In [year], I was involved in the care of a patient with [condition]. [Brief description of clinical situation]. A claim was filed alleging [allegation]. The case was [resolved how] in [year]. [Any relevant context, e.g., 'I was one of multiple defendants' or 'The case was dismissed on summary judgment']."
What Not to Write
- Lengthy defensive narratives
- Blame directed at patients, colleagues, or the legal system
- Minimization ("it was nothing")
- Excessive detail about clinical care
- Legal arguments about why you weren't liable
Special Situations
Pending Claims
If you have an active lawsuit:
- Disclose that a claim is pending
- Provide basic information
- Consult your malpractice attorney about what to say
- Update credentialing organizations when resolved
Multiple Claims
If you have multiple claims:
- Disclose all that fall within the look-back period
- Pattern matters—committee may look at totality
- Consider whether practice changes are appropriate
- High-risk specialties may be evaluated differently
Settlements Without Fault Admission
Many settlements include "no admission of fault" language. This doesn't mean you shouldn't disclose:
- The payment still gets reported to NPDB
- You must still disclose when asked about settlements
- You can note that it was resolved without admission of fault
Named But Not Primary Defendant
If you were named in a suit but weren't the primary defendant:
- Still must disclose if asked about claims against you
- Can explain your peripheral involvement
- Note if you were dismissed from the case
Impact on Credentialing
How Claims Are Evaluated
Credentialing committees typically consider:
- Number of claims relative to specialty and practice volume
- Severity and nature of allegations
- Pattern or isolated incidents
- Time elapsed since claims
- Outcome (dismissed vs. large judgment)
- Your explanation and insight
What Raises Concern
- Multiple claims suggesting a pattern
- Egregious conduct allegations
- Recent claims (more weight than old ones)
- Non-disclosure of known claims
- Inconsistent information across applications
What Provides Reassurance
- Claims consistent with specialty risk profile
- Isolated incidents with long claim-free periods
- Claims dismissed or resolved favorably
- Thoughtful explanation showing insight
- Complete, consistent disclosure
Practical Steps
Before Applying
- Self-query NPDB
- Gather documentation on all claims
- Prepare standard explanation language
- Consult attorney if needed
During Application
- Answer all questions completely
- Use consistent language across applications
- Provide documentation if requested
- Follow up on any committee questions
Ongoing
- Update credentialing files when new claims arise
- Notify organizations of claim resolutions
- Keep documentation organized for future applications
Working with Your Malpractice Carrier
Documentation from Carrier
Your malpractice insurance carrier can provide:
- Claims history letter
- Details on dates, amounts, outcomes
- Loss runs (summary of claims)
Coordination on Disclosure
For pending claims, coordinate with your carrier/attorney on:
- What can be disclosed
- How to characterize the claim
- What documentation to provide
Conclusion
Malpractice claims complicate credentialing but don't prevent it. The key is complete, consistent, honest disclosure with thoughtful explanation. Credentialing committees understand that claims are part of medical practice—what concerns them is non-disclosure, patterns suggesting problems, or defensive responses that show lack of insight.
Self-query your NPDB before applying, prepare clear explanation language, disclose everything that's asked about, and present the information professionally. Most physicians with malpractice history continue to be credentialed successfully.
Key Takeaways
- Always disclose: Non-disclosure is worse than the claim
- Self-query NPDB: Know what's reported before applying
- Be factual, not defensive: Brief, objective explanations
- Consistency matters: Same information across all applications
- Context helps: Specialty, practice volume, isolated vs. pattern
- Update as needed: Notify when claims resolve
References
[1]: NPDB - Self-Query Information https://www.npdb.hrsa.gov/
[2]: AMA - Medical Liability Reform https://www.ama-assn.org/
[3]: PIAA - Malpractice Claims Data https://www.piaa.us/