DOD HEALTH CARE

Actions Needed to 

Help Ensure Full 

Compliance and 

Complete 

Documentation for 

Physician 

Credentialing and 

Privileging

Report to Congressional Requesters

December 2011

GAO-12-31

United States Government Accountability Office

GAO
United States Government Accountability Office

Highlights of GAO-12-31, a report to 

congressional requesters

December 2011

DOD HEALTH CARE

Actions Needed to Help Ensure Full Compliance and 

Complete Documentation for Physician 

Credentialing and Privileging

Why GAO Did This Study

The process of credentialing and 

privileging is central to ensuring that 

physicians who work in DOD military 

treatment facilities (MTF) have the 

appropriate credentials and clinical 

competence. After an Army physician 

allegedly shot and killed 13 people at 

Fort Hood in November 2009, GAO 

was asked to examine DOD’s 

physician credentialing and privileging 

requirements and whether MTFs are 

fully complying with those 

requirements. GAO examined the 

extent to which: (1) DOD ensures that 

physician credentialing and privileging 

requirements are consistent across the

Military Health System (MHS), (2) 

Army MTFs are complying with Army’s 

physician credentialing and privileging 

requirements, and (3) Army’s existing 

oversight and physician credentialing 

and privileging requirements are 

sufficient to assure compliance and 

complete documentation. GAO 

reviewed DOD and service-level 

requirements and interviewed DOD 

and military service officials. Because 

Army has the largest staff of medical 

personnel, GAO reviewed a 

nongeneralizable sample of 150 

physician credentials files—selected to 

include a variety of specialties—and 

interviewed staff at five Army MTFs 

selected based on size and location. 

What GAO Recommends

GAO is making recommendations to 

ensure consistency across MHS 

requirements; to better ensure that 

performance data and other relevant 

information are documented; and to 

improve oversight across the MHS. 

DOD agreed overall, but DOD’s 

response lacks sufficient detail to 

determine how fully its planned actions 

will address the recommendations.

What GAO Found

DOD and the military services—Army, Navy, and Air Force—each establish 

requirements for reviewing physician credentials and competence, but the 

military services’ requirements are in some cases inconsistent with DOD’s 

requirements and each other’s. For example, DOD requires disclosure and 

primary source verification of all state medical licenses a physician has ever held; 

Navy only requires these steps for licenses held during the previous 10 years. 

Inconsistencies also exist between DOD’s and the services’ requirements for the 

use of and primary source verification of certain clinical competence and practice 

history documents. Such differences may result in MTF noncompliance with 

requirements that DOD deems important. They may also create challenges for 

ensuring that all requirements are met for physicians from one military service 

who are working at an MTF managed by another service. Furthermore, DOD 

lacks a systematic process to address inconsistencies across requirements, to 

coordinate revisions to the requirements, and to achieve its goal of standardizing 

physician credentialing and privileging requirements across the MHS.

The five Army MTFs GAO examined did not fully comply with certain Army 

physician credentialing and privileging requirements. For 34 of the 150 

credentials files GAO reviewed, the MTF had not documented proper verification 

of every state medical license the physician ever held at the time the MTF 

granted privileges; 7 of these 34 credentials files lacked this documentation for 

the physician’s only current medical license. In addition, credentials files did not 

consistently contain documents required to support the physician’s clinical 

competence, including peer recommendations and performance assessments; 

14 files were missing required peer recommendations and 21 files were missing 

required performance assessments. Further, MTFs were not consistently 

documenting follow-up conducted on peer recommendations, as required. When 

required documents were present, they sometimes lacked required information. 

For example, performance assessments did not consistently contain data to 

support the assessment, even when an MTF’s form specifically prompted for it. 

MTFs also lacked a systematic process for compiling and analyzing performance 

data. Finally, while MTFs usually complied with Army’s requirement to search 

physicians’ malpractice history, files often lacked information needed to 

determine if the MTF had documented a complete practice history, as required. 

Army oversight processes and requirements were insufficient to assure that its 

MTFs fully complied with requirements and documented complete information to 

support credentialing and privileging decisions. Army oversight of individual 

MTFs’ privileging decisions was insufficient to identify the instances of 

noncompliance and incomplete documentation that GAO observed during its 

review of credentials files at five selected Army MTFs. In particular, Army lacks a 

process for reviewing individual MTFs’ credentials files to identify these issues, 

as do Navy and Air Force. Moreover, weaknesses in Army requirements 

contributed to noncompliance and incomplete documentation. For example, 

MTFs did not consistently document follow-up on peer recommendations, in part 

because existing requirements do not clearly delineate responsibilities for 

documenting follow-up. Further, Army lacks requirements for documenting 

certain types of information—such as information on significant MTF 

deliberations—needed to support credentialing and privileging decisions.

View GAO-12-31. For more information, 

contact Randall B. Williamson at (202) 512-

7114 or williamsonr@gao.gov.
Page i GAO-12-31 DOD Credentialing and Privileging

Letter 1 

Background 6

DOD Lacks a Process to Ensure Physician Credentialing and 

Privileging Requirements Are Consistent Across the MHS 14

Selected Army MTFs Did Not Fully Comply with Certain Army 

Physician Credentialing and Privileging Requirements 19

Army Oversight and Physician Credentialing and Privileging 

Requirements Were Insufficient to Assure that MTFs Fully 

Complied and Documented Complete Information 30

Conclusions 39

Recommendations for Executive Action 41

Agency Comments and Our Evaluation 42

Appendix I Scope and Methodology 46

Appendix II Comments from the Department of Defense 53

Appendix III GAO Contact and Staff Acknowledgments 57

Tables

Table 1: Extent that Military Services’ Physician Credentialing and 

Privileging Requirements Are Consistent with DOD’s 

Requirements, and Potential Consequences of Inconsistent 

Requirements, as of September 2011 15

Figures

Figure 1: Organization of Physician Credentialing and Privileging 

within the Military Health System 9

Figure 2: Example of a Peer Recommendation that Could Raise 

Concern 24

Figure 3: Examples of Data Provided in Form 5374s at Army MTFs 

GAO Selected for its Review 26

Contents
Page ii GAO-12-31 DOD Credentialing and Privileging

Abbreviations

AFMOA Air Force Medical Operations Agency 

BUMED Bureau of Medicine and Surgery

CCQAS Centralized Credentials Quality Assurance System 

CV curriculum vitae 

DOD Department of Defense

DPDB Defense Practitioner Data Bank

ICTB inter-facility credentials transfer brief 

MHS Military Health System

MTF military treatment facility

NPDB National Practitioner Data Bank 

PAF provider activity file

PSV primary source verification 

VA Department of Veterans Affairs

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. The published product may be reproduced and distributed in its entirety 

without further permission from GAO. However, because this work may contain 

copyrighted images or other material, permission from the copyright holder may be 

necessary if you wish to reproduce this material separately.
Page 1 GAO-12-31 DOD Credentialing and Privileging

United States Government Accountability Office

Washington, DC 20548

December 15, 2011

The Honorable Jason Chaffetz

Chairman

The Honorable John Tierney

Ranking Member

Subcommittee on National Security, Homeland Defense 

 and Foreign Operations

Committee on Oversight and Government Reform

House of Representatives

The Honorable Jeff Flake

House of Representatives

The Department of Defense (DOD) requires each of the military 

services—the Departments of the Army, Navy, and Air Force—to take 

specific steps to determine whether physicians have the appropriate 

professional qualifications and clinical abilities to care for the 

servicemembers and their families treated in the Military Health System 

(MHS). These steps begin with the process of credentialing and 

privileging each physician before the physician is allowed to treat patients 

at a DOD military treatment facility (MTF).1

 

1

An MTF is a military treatment facility owned and operated by DOD that is established for 

the purpose of furnishing medical and/or dental care to eligible individuals. 

During the credentialing 

process, the MTF staff collects and reviews information such as a 

physician’s professional training, malpractice history, peer 

recommendations, and other documents regarding their professional 

background to determine whether the physician has suitable clinical 

abilities and experience to practice at the MTF. During the privileging 

process, the MTF staff determines which specific health care services—

known as clinical privileges—the physician should be allowed to provide, 

based on the physicians’ clinical competence to provide the service and 

the specific capabilities of the MTF. After the physician is granted 

privileges, the credentialing and privileging processes are repeated at 

least every 2 years. During these 2 years, or in between privileging dates, 

DOD also requires MTFs to conduct ongoing monitoring of physicians’ 

clinical performance to help ensure physicians’ clinical competence.

 
 

Page 2 GAO-12-31 DOD Credentialing and Privileging

The events at Fort Hood in November 2009, where an active duty Army 

physician allegedly shot and killed 13 people, have led to questions about 

how well DOD and the military services are monitoring, evaluating, and 

documenting the competence of their physicians. An independent 

investigation of the events at Fort Hood focused mainly on evaluating 

DOD’s and the military services’ policies and procedures for identifying 

potential safety threats, but it also included a review of the alleged 

perpetrator’s medical training records.2

The events at Fort Hood and the findings of the subsequent investigation 

raise questions about whether the military services’ individual networks of 

MTFs are fully complying with DOD’s physician credentialing and 

privileging requirements and appropriately implementing credentialing 

and privileging processes. To implement DOD’s credentialing and 

privileging processes at their MTFs, each military service has established 

its own specific credentialing and privileging requirements that its MTFs 

must follow.

The investigation identified 

discrepancies between the alleged perpetrator’s performance as 

documented in official records and his actual performance during his 

medical training, residency, and fellowship in an Army MTF. The 

investigation also identified gaps in processes for ensuring that all 

relevant information about physician performance is included in the formal 

evaluation process and made available to supervisors.

3 Each military service, under a surgeon general, has a 

central oversight agency—sometimes referred to as a medical 

command—with the delegated responsibility to lead the development and 

implementation of these service-specific requirements. However, as we 

have previously reported, there have been long-standing concerns about 

management challenges and potential inefficiencies related to the current 

MHS structure.4

 

2

U.S. Department of Defense Independent Review, Protecting the Force: Lessons from 

Fort Hood (Washington, D.C.: Jan.15, 2010).

In both 2010 and 2011, defense authorization bills 

passed by the House contained provisions relating to the establishment of 

3

Most MTFs are managed by a specific military service; Army, Navy, or Air Force, with 

Navy providing health care to the Marine Corps. However, some MTFs—such as the 

Walter Reed National Military Medical Center in the National Capital Region—are jointly 

managed by more than one service, and some facilities are jointly managed by DOD and 

the Department of Veterans Affairs (VA).

4

GAO, Defense Health Care: DOD Needs to Address the Expected Benefits, Costs, and 

Risks for Its Newly Approved Medical Command Structure, GAO-08-122 (Washington, 

D.C.: Oct. 12, 2007).
 

Page 3 GAO-12-31 DOD Credentialing and Privileging

a unified medical command system within the MHS.5 Further, DOD has

established goals for the MHS to standardize processes across the 

military services, including physician credentialing and privileging 

processes.6

In this context, you asked us to review the military services’ policies and 

procedures for verifying physician credentials and clinical competence. In 

this report we examine the extent to which: (1) DOD ensures that the 

military services’ physician credentialing and privileging requirements are 

consistent across the MHS, (2) Army MTFs are complying with Army’s 

physician credentialing and privileging requirements, and (3) Army’s 

existing oversight and physician credentialing and privileging 

requirements are sufficient to assure compliance and complete 

documentation.

Standardizing these processes is intended to improve the 

ability of the military services to share information, particularly as it relates 

to MTFs’ ability to obtain and review credentialing and privileging 

documents for all DOD health professionals.

To examine the extent to which DOD ensures that the military services’ 

physician credentialing and privileging requirements are consistent with 

DOD’s, we reviewed written policies issued by DOD, Army, Navy, and Air 

Force.7 We also reviewed applicable standards published by The Joint 

Commission (a nonprofit organization that evaluates and accredits more 

than 16,000 health care organizations in the United States, including 

MTFs).8

 

5

H.R. 5136, 111th Cong. § 903 (as passed by House, May 28, 2010); H.R. 1540, 112th 

Cong. § 711 (as passed by House, May 26, 2011). Neither provision has become law.

We compared DOD’s and the military services’ requirements 

related to primary source verification of physician credentials, evaluation 

6

U.S. Department of Defense, MHS Human Capital Strategic Plan 2008-2013

(Washington, D.C.: November 2007). 

7

Written policies used for analysis include DOD Instruction 6025.13 (which replaced DOD 

Directive 6025.13 on February 17, 2011), DOD Regulation 6025.13-R, Army Regulation 

40-68, Navy Bureau of Medicine and Surgery Instruction 6320.66E, and Air Force 

Instruction 44-119. Throughout this report, we refer to these policies as “requirements.” 

When we use the term “regulations,” we are referring to specific written policy documents 

labeled as such by the issuer.

8

DOD requires that all MTFs shall meet or exceed the standards of appropriate external 

accrediting bodies, including accreditation of all hospitals by The Joint Commission. In 

order to be accredited by The Joint Commission, each MTF is subject to on-site review 

once every 3 years. 
 

Page 4 GAO-12-31 DOD Credentialing and Privileging

of physician performance and clinical competence, and documentation of 

physician practice history. Specifically, we compared requirements 

regarding state medical licenses, peer recommendations, ongoing 

performance monitoring and assessment, malpractice and adverse action 

history, and practice experience. We selected these five credentialing and 

privileging requirements because they—unlike other requirements—

address information about physicians that can change or be updated with 

new information periodically. To gain further understanding of efforts to 

standardize physician credentialing and privileging processes across the 

MHS, we also reviewed DOD strategy documents, including the MHS 

Human Capital Strategic Plan 2008-2013. To obtain further information 

regarding interpretation of requirements, the processes in place to help 

ensure consistency between DOD and the military services and among 

the military services themselves, and efforts to standardize processes, we 

interviewed officials from DOD and from each military service’s oversight 

agency.9

To determine the extent to which Army MTFs are complying with the 

Army’s requirements for credentialing and privileging of physicians, we 

conducted site visits to five Army MTFs in the United States. We limited 

our compliance review to Army MTFs because it is the military service 

with the largest staff of medical personnel.10

 

9

We interviewed senior officials who are responsible for developing and overseeing 

DOD’s and the military services’ physician credentialing and privileging requirements. 

These officials included the Deputy Assistant Secretary of Defense for Clinical and 

Program Policy; the Chief of Quality Management Division for the U.S. Army Medical 

Command; the Deputy Department Head of Clinical Operations Quality and Risk 

Management for the Navy Bureau of Medicine and Surgery; and the Chief of Professional 

Staff Management for the Air Force Medical Operations Agency. During most interviews 

more than one official was present; however, in some follow-up interviews, only the senior 

official was present.

We selected the MTFs in our 

sample to ensure variation in terms of the size of the MTFs and that each 

MTF had a sufficient number of physicians within each of six selected 

10The number of fixed MTFs managed by each military service varies, and each service’s 

MTFs may be located either in the United States or overseas. The Army operates 35 

MTFs, including 9 medical centers. The Navy operates 31 MTFs, including 3 medical 

centers. The Air Force operates 72 MTFs, including 3 medical centers. We did not 

evaluate compliance at MTFs located overseas. At the time we began our review, the 

National Naval Audit Service was conducting a review of Navy’s credentialing and 

privileging process and was using a similar file review methodology.
 

Page 5 GAO-12-31 DOD Credentialing and Privileging

medical specialties.11

To determine the extent to which Army’s existing oversight and physician 

credentialing and privileging requirements are sufficient, we reviewed 

information collected during our site visits to selected Army MTFs, 

reviewed relevant internal controls standards, and interviewed MTF staff 

and officials from Army Medical Command. Specifically, we considered 

Army’s oversight, including the provision of policy and guidance, against 

relevant standards described in the Standards for Internal Control in the 

Federal Government and the Internal Control Management and 

Evaluation Tool.

We found the Army data we used to make this 

selection to be sufficiently reliable for our purposes. During our site visits 

to each of the five Army MTFs, we selected and reviewed a 

nongeneralizable sample of 30 physician credentials files (5 in each of the 

selected medical specialties), for a total of 150 files. However, results for 

some of the credentialing and privileging requirements do not total 150 

because not all credentials files were required to comply with every 

requirement we examined. We also reviewed MTF-specific forms, such 

as peer recommendation forms and official performance assessment 

templates and minutes from meetings of the MTF committee responsible 

for reviewing physician credentials files, for the 2 years prior to our site 

visit. During our site visits, we interviewed MTF staff responsible for 

maintaining credentials files, MTF department chiefs, and other MTF staff 

responsible for reviewing credentials files and recommending privileges 

for physicians. We reviewed with MTF staff at the end of each visit all 

instances of documentation we were unable to locate. The results of our 

site visits to selected Army MTFs cannot be generalized to all Army 

MTFs, or MTFs managed by the Navy or the Air Force.

12

 

11We selected the medical specialties of Family Practice, Obstetrics-Gynecology, 

Pediatrics, Psychiatry, Radiology, and Surgery. We selected these medical specialties in 

order to ensure that we had a sufficient number of physicians within each medical 

specialty to have a consistent sample of specialties across the five MTFs, and also to 

ensure that our sample could not be used to identify specific individuals at each MTF.

We also reviewed information obtained during our site 

12GAO, Standards for Internal Control in the Federal Government GAO/AIMD-00-21.3.1

(Washington, D.C.: November 1999). Internal control is synonymous with management 

control and comprises the plans, methods, and procedures used to meet missions, goals, 

and objectives. The Internal Control Management and Evaluation Tool is based on the 

Standards for Internal Control in the Federal Government, and is intended to provide a 

systematic approach to assessing an agency’s internal control structure. See GAO, 

Internal Control Management and Evaluation Tool, GAO-01-1008G (Washington, D.C.: 

August 2001).
 

Page 6 GAO-12-31 DOD Credentialing and Privileging

visits, including our reviews of select physician credentials files, MTFspecific forms, and relevant minutes from MTF meetings pertaining to 

credentialing and privileging. Lastly, we interviewed MTF staff, officials 

from DOD, and officials from each military service’s oversight agency to 

gain insight into current oversight processes for physician credentialing 

and privileging.

Further details on our scope and methodology can be found in appendix I. 

We conducted this performance audit from May 2010 to December 2011 

in accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

Within the MHS, the military services each have a network of MTFs. 

These MTFs are located both in the United States and abroad, and they 

vary in size from small clinics to large medical centers. The physician 

population at the MTFs within the MHS is diverse—including active duty, 

Reserve, and National Guard servicemembers, as well as civilians, 

contractors, VA staff, and volunteers. MHS physicians are assigned to a 

specific MTF, which is referred to as their duty station. However, 

physicians within the MHS frequently move among MTFs. Military 

physicians can be reassigned to a new duty station as frequently as every 

2 to 3 years, and most physicians working at an MTF can be temporarily 

assigned to work at another MTF to assist DOD’s mission needs.13

In order to care for servicemembers and their families at an MTF, a 

physician must have the required credentials and be granted the 

appropriate, specific privileges for their medical specialty. Credentialing is 

the process of inspecting and authenticating the documents that 

Furthermore, individual MTFs can be staffed by physicians from more 

than one military service.

 

13Military physicians can also be deployed for service overseas.

Background 

Structure for Physician 

Credentialing and 

Privileging in the Military 

Health System
 

Page 7 GAO-12-31 DOD Credentialing and Privileging

constitute evidence of appropriate education, training, licensure, and 

experience. Privileging is the process that defines the scope and limits of 

practice for a physician based on their relevant training and experience, 

current competence, peer recommendations, and the capabilities of the

facility where the physician is practicing.

The Assistant Secretary of Defense for Health Affairs within DOD is 

responsible for developing and overseeing DOD’s physician credentialing 

and privileging requirements to ensure their consistent application across 

the MHS.14

Generally, DOD delegates oversight of physician credentialing and 

privileging at MTFs to each of the military services’ Surgeons General, 

who then further delegate oversight to each of the services’ responsible 

oversight agencies: U.S. Army Medical Command, Navy’s Bureau of 

Medicine and Surgery (BUMED), and the Air Force Medical Operations 

Agency (AFMOA). Army and Navy also have a regional command 

structure, which has some responsibilities for overseeing credentialing 

and privileging at their MTFs. Within each MTF, the MTF commander—

who is the final “privileging authority”—is responsible for ensuring that the 

MTF complies with all applicable DOD and service physician credentialing 

and privileging requirements. In addition, MTF staff such as members of 

To implement DOD’s requirements, the military services’ 

Surgeons General—who are delegated the responsibility by the Secretary 

of their respective service—establish specific physician credentialing and 

privileging requirements, with which their MTFs are required to comply. 

Each military service has a central oversight agency that is responsible 

for developing and implementing service-specific requirements. Moving 

forward, DOD strategy documents have established broad goals for 

standardizing processes and improving information-sharing across the 

MHS. For example, the MHS Human Capital Strategic Plan for 2008-2013

established the goal to define and deploy a common credentialing and 

privileging system across the military services. These strategic plans also 

established goals for ensuring that information is accessible to MHS 

leaders at all levels to promote informed decision making.

 

14DOD Instruction 6025.13 and the associated DOD Regulation 6025.13-R—both of which 

contain procedures for physician credentialing and privileging—require the Assistant 

Secretary of Defense for Health Affairs to ensure their consistent implementation across 

the MHS. DOD Regulation 6025.13-R is mandatory for use by all DOD components. DOD 

also requires that each MTF comply with applicable hospital accreditation standards of 

The Joint Commission.
 

Page 8 GAO-12-31 DOD Credentialing and Privileging

the credentials committee,15 department chiefs,16

 

15The credentials committee is a group of MTF staff—typically made up of department 

chiefs and other appointed staff—that is responsible for reviewing each physician’s 

application for privileges and making recommendations to the MTF commander on 

whether to grant privileges. 

and credentials staff—

staff at each MTF dedicated to the credentialing and privileging process—

have varying responsibilities for implementing physician credentialing and 

privileging processes. (See fig. 1.)

16In many cases, the department chief is the physician’s clinical supervisor. However, in 

larger MTFs, this may not be the case. In all MTFs, the department chief is responsible for 

reviewing the physician’s application for privileges prior to the credentials committee’s 

review, so for the purposes of this report we focused on department chiefs’ responsibilities 

in the credentialing and privileging processes.
 

Page 9 GAO-12-31 DOD Credentialing and Privileging

Figure 1: Organization of Physician Credentialing and Privileging within the Military Health System

During the credentialing process, credentials staff collect and review each 

physician’s medical credentials, such as state medical licenses and 

medical education, to determine whether the physician has the 

qualifications required by DOD to provide care at an MTF. During this 

process, some of the medical credentials must be primary source verified, 

which involves collecting documentation from the original source for each 

credential to confirm the factual accuracy and authenticity of the 

physician-provided documentation.

Physician Credentialing 

and Privileging Processes 

in the Military Health 

System
 

Page 10 GAO-12-31 DOD Credentialing and Privileging

During the privileging process, MTF staff—typically department chiefs, 

members of the credentials committee, and the MTF commander—review 

available performance information on each physician to determine which 

specific health care services the physician is clinically competent to 

practice. Initial privileges are usually granted for 1 year, after which a 

physician must submit a request for the renewal of their clinical privileges. 

This renewal process is then repeated at least every 2 years.

The steps in the credentialing and privileging processes are essentially 

the same across the military services. The general processes include the 

following steps:

• A physician completes an application for privileges, in which the 

physician requests specific clinical privileges and provides all the 

required information on their medical credentials to the MTF’s 

credentials staff.

• The MTF’s credentials staff then conducts any required primary 

source verification of information, such as the physician’s state 

medical licenses, and collects other required documents such as peer 

recommendations. For a physician who already holds privileges at the 

MTF, the credentials staff will obtain an assessment of current 

performance from the department chief.17 The credentials staff then 

compiles the required documents and the physician’s application for 

privileges into a credentials file and submits them to the department 

chief.

• The department chief is responsible for reviewing the physician’s 

credentials file, including practice history, peer recommendations, and 

performance assessments. Based on this information, the department 

chief makes a recommendation to the committee designated to review 

the credentials file—usually the credentials committee—on whether to 

grant the requested privileges.

• The credentials committee reviews the department chief’s 

recommendation and the physician’s credentials file, along with any 

other input during the committee meeting. The credentials committee, 

 

17Performance assessments should cover the time period since the MTF last granted 

privileges to the physician.
 

Page 11 GAO-12-31 DOD Credentialing and Privileging

or the chairperson, then makes a recommendation regarding 

privileges to the MTF commander.

• The MTF commander reviews the credentials committee’s 

recommendation and makes the final determination on whether to 

grant the requested privileges to the physician.

To facilitate the credentialing and privileging processes, MTFs are 

required to maintain a credentials file for any physician practicing within 

the MHS. The credentials file contains information relevant to both 

credentialing and privileging a physician, and includes information on a 

physician’s credentials, clinical competence, and practice history. Types 

of information contained in the credentials file may include:

• Credentials Verification Information: documentation of required 

primary source verification of a physician’s medical education, 

training, state medical licenses,18 and certifications such as life 

support training.19

• Clinical Competence Information: documentation includes information 

such as peer recommendations and performance assessments to 

support a physician’s current clinical competence to perform the 

requested clinical privileges.

• Practice History Information: documentation of a physician’s prior 

practice, including:

• any paid malpractice claims that were reported to the National 

Practitioner Data Bank (NPDB),20

 

18A physician may hold a medical license in more than one state. A medical license can 

have one of several different statuses, including active, expired, inactive, restricted, 

suspended, or revoked.

19Examples of these certifications include Basic Life Support, Advanced Cardiac Life 

Support, Advanced Trauma Life Support, Pediatric Advanced Life Support, and Neonatal 

Advanced Life Support.

20The NPDB is administered by the U.S. Department of Health and Human Services and 

includes information on physicians who either have been disciplined by a state medical 

board, professional society, or health care provider or have been named in a medical 

malpractice settlement or judgment.
 

Page 12 GAO-12-31 DOD Credentialing and Privileging

• any relevant information in DOD’s Defense Practitioner Data Bank 

(DPDB)21 such as disability or other payment made due to the 

death or injury of an active duty member of the military services, 

and

• any additional information related to the physician’s prior practice 

experience.

A credentials file within the MHS is a combination of paper and electronic 

files. In 2000, DOD introduced its Centralized Credentials Quality 

Assurance System (CCQAS), an on-line data system for use by all three 

of the military services’ oversight agencies. CCQAS allows MTFs to 

electronically manage information related to a physician’s credentialing 

and privileging. When a physician is reassigned to a new duty station, the 

paper credentials file transfers with the physician to their new duty station, 

which also gains access to and control of the physician’s electronic 

credentials file in CCQAS. CCQAS consists of four modules:

• The credentials module of CCQAS, considered the electronic 

credentials file, contains information related to a physician’s medical 

education and training, clinical competence, and practice history.

• The privileging module allows a physician to request privileges 

electronically. It also allows the MTF to review a physician’s 

application and grant privileges electronically.

• The risk management module contains any information maintained by 

the MTF on malpractice settlements, claims, and potentially 

compensable events.22

• The adverse actions module contains information maintained by the 

MTF on any actions taken to limit a physician’s privileges, including 

suspension, restriction, revocation, or denial.

 

21In addition to including information that DOD has reported to the NPDB, the DPDB 

includes information on instances where medical care contributed to the death or disability 

of an active duty service member. 

22A potentially compensable event is an adverse event in which a patient experiences an 

unintended or unexpected negative result which may result in a medical malpractice claim 

or settlement.
 

Page 13 GAO-12-31 DOD Credentialing and Privileging

Together, the risk management and adverse action modules in CCQAS 

comprise the DPDB.23

In addition to the general credentialing and privileging processes 

described above, DOD and the military services have developed an 

abbreviated process to facilitate the movement of physicians across 

MTFs. This process, predicated upon the use of a single document 

known as the inter-facility credentials transfer brief (ICTB), allows a 

“receiving” MTF to privilege a physician without duplicating efforts already 

taken by the physician’s assigned duty station. For example, the receiving 

MTF would not need to obtain new peer recommendations for a physician 

who is being granted privileges based on an ICTB.

However, unlike information in the privileging

module, which is transferred when a physician is reassigned to a new 

duty station, information in the risk management and adverse action 

modules can only be accessed by the MTF that recorded it.

24 To initiate the ICTB 

process, the “sending” MTF will send a summary—the ICTB—of 

information regarding the physician’s credentials, along with a statement 

attesting to the physician’s clinical competence to the receiving MTF. The 

ICTB then serves in place of the physician’s credentials file at the 

receiving MTF, and may be used both between MTFs managed by a 

single military service and between MTFs managed by more than one 

military service. In addition to the paper ICTB, the receiving MTF also can 

view any electronic information on the physician in CCQAS, although in 

general the receiving MTF cannot edit any of the information on a 

physician in CCQAS.

 

23For each malpractice claim or potentially compensable event that occurs at an MTF, the 

MTF is required to review the care provided by each involved physician and make a 

formal determination of whether the physician met or did not meet the applicable standard 

of care, or if the case was indeterminate.

24Reliance on the ICTB may result in the receiving MTF applying different credentialing 

and privileging requirements for physicians granted privileges based on an ICTB. 
 

Page 14 GAO-12-31 DOD Credentialing and Privileging

DOD and the military services have each established requirements for the 

review of physician credentials and the granting of privileges, but the 

military services have established requirements that are in some cases 

inconsistent with DOD’s requirements and each other’s. DOD does not 

have a process in place to identify and address these inconsistencies 

across the MHS.

All the military services require their MTFs to comply with DOD’s 

requirements. However, we found some inconsistencies between the 

military services’ requirements for credentialing and privileging and 

DOD’s requirements in four of the five categories we reviewed, 

specifically, state medical licensure; peer recommendations; malpractice 

history; and practice experience. We also identified some potential 

consequences of these inconsistencies. (See table 1.) For example, DOD 

requires MTFs to verify peer recommendations with the primary source. 

While Army and Navy have incorporated this into their requirements, Air 

Force requires that peer recommendations be verified but does not 

specify that this verification must be with the primary source. Air Force 

MTFs may therefore lack assurance that the peer recommendations they 

have received for a physician are authentic documents.

DOD Lacks a Process 

to Ensure Physician 

Credentialing and 

Privileging

Requirements Are 

Consistent Across the 

MHS

Physician Credentialing 

and Privileging 

Requirements Are Not 

Always Consistent Across 

the MHS
 

Page 15 GAO-12-31 DOD Credentialing and Privileging

Table 1: Extent that Military Services’ Physician Credentialing and Privileging Requirements Are Consistent with DOD’s 

Requirements, and Potential Consequences of Inconsistent Requirements, as of September 2011

DOD requirement Army Navy

Air 

Force

Details of inconsistent 

requirements

Potential consequences of 

inconsistent requirements

State medical licensure

Physician maintenance of 

current, valid, unrestricted 

license

Yes Yes Yes

Physician disclosure of all 

licenses ever held

Yes No Yes a Navy requires disclosure of 

licenses held in the past 10 years.

Military treatment facilities (MTF) may 

not have information on actions taken 

against an undisclosed previous 

license from more than 10 years 

prior. 

Primary source 

verification (PSV) of all 

licenses ever held

Yes No Yes a Navy requires PSV of licenses held 

in the past 10 years.

MTFs may lack assurance on the 

authenticity of any license from more 

than 10 years prior and on the 

accuracy of information on actions 

taken against a previous license from 

more than 10 years prior.

Peer recommendations

Required for all 

physicians

Yes No No Navy requires peer 

recommendations for physicians 

new to the Navy. Performance 

Appraisal Report allowed for 

physicians coming from a Navy 

MTF.

Air Force requires peer 

recommendations for physicians 

new to the specific MTF. 

Performance assessment Air Force 

Form 22 allowed for physicians 

renewing privileges.

In substituting performance 

assessments for peer 

recommendations, MTFs may not 

have consistent information regarding 

physicians’ clinical competence.

Two recommendations 

required for a physician

Yes Yes Yes b

PSV of required peer 

recommendations

Yes Yes No Air Force required to “verify” but 

no further clarification as to 

whether that verification must be 

with the primary source.

MTFs may lack assurance that peer 

recommendations are authentic 

documents.

Ongoing performance monitoring 

Periodic reviews of 

performance 

Yes Yes Yes
 

Page 16 GAO-12-31 DOD Credentialing and Privileging

DOD requirement Army Navy

Air 

Force

Details of inconsistent 

requirements

Potential consequences of 

inconsistent requirements

Malpractice history

National Practitioner Data 

Bank (NPDB) query 

required at privileging

Yes Yes Yes

Defense Practitioner Data 

Bank (DPDB) query 

required at renewal of 

privileges

No No Yes Army has no specific requirement.

Navy has no specific requirement.

MTFs may not have the complete 

malpractice history information 

needed to make privileging decisions.

Document any 

malpractice claims, 

settlements, judicial or 

administrative 

adjudications, and 

adverse or disciplinary 

actions

Yes Yes Yes

PSV malpractice 

history—other than NPDB

Yes No No Navy required to “verify” but no 

further clarification as to whether 

that verification must be with the 

primary source.

Air Force required to “verify” but 

no further clarification as to 

whether that verification must be 

with the primary source.

MTFs may lack assurance that 

physician-provided information is 

accurate.

Practice experience

Chronological 

documentation of practice 

experience accounting for 

all periods of time is 

required at privileging

Yes Yes Yes

PSV of documentation of 

practice history

No No No Army has no specific requirement.

Navy required to “verify” but no 

further clarification as to whether 

that verification must be with the 

primary source.

Air Force required to “verify” but 

no further clarification as to 

whether that verification must be 

with the primary source.

MTFs may lack assurance that 

physician-provided information is 

accurate.

Source: GAO analysis.

Note: Written policies used for analysis include DOD Instruction 6025.13 (which replaced DOD 

Directive 6025.13 on February 17, 2011), DOD Regulation 6025.13-R, Army Regulation 40-68, Navy

Bureau of Medicine and Surgery (BUMED) Instruction 6320.66E, and Air Force Instruction 44-119. 

a

Navy officials informed us that the Navy’s current revisions process includes plans to revise Navy 

BUMED Instruction 6320.66E to require that physicians disclose, and Navy MTFs primary source 

verify, all licenses ever held.

b

Navy (to the extent it requires recommendations) does not specify a number beyond “letters.” 
 

Page 17 GAO-12-31 DOD Credentialing and Privileging

Since the military services require their MTFs to comply with DOD’s 

requirements, the inconsistencies we identified between DOD’s and the 

military services’ requirements could result in one or more of the military 

services not complying with credentialing and privileging processes that 

DOD deems to be important. For example, DOD requires MTFs to query 

the DPDB at renewal of privileges, but Army requirements are silent on 

this requirement. Because Army does not have a specific requirement for 

MTFs to query the DPDB at renewal of privileges, Army MTFs may not be 

performing these queries. Additionally, DOD, Army, Navy, and Air Force 

officials told us that it is currently not possible for MTFs to query the 

DPDB for results from other MTFs.25

The inconsistencies in physician credentialing and privileging 

requirements across the military services themselves also have potential 

consequences. First, the inconsistencies conflict with DOD’s stated goal 

of standardizing these processes across the military services and 

improving the ability of the military services to share credentialing and 

privileging information. Second, these inconsistencies may create 

challenges related to ensuring that all applicable requirements have been 

met for physicians from one service who are granted privileges at another 

service’s MTF on the basis of an ICTB in place of a full credentials file. 

For example, a Navy MTF may only have the disclosure and primary 

source verification of a physician’s licenses from the past 10 years, which 

meets Navy’s requirements. If that physician is later temporarily 

transferred to an Army MTF using an ICTB, the receiving Army MTF, 

which requires the disclosure and primary source verification of all 

licenses ever held, would risk making privileging decisions on information 

that would be insufficient to meet Army requirements. The responsible 

DOD official acknowledged that inconsistencies across the military 

services’ requirements could be a problem and noted that DOD would like 

to move towards standardizing physician credentialing and privileging 

requirements.

Without obtaining all relevant 

information from the DPDB, MTFs may be missing information DOD 

deems important to the credentialing and privileging process.

 

25MTFs can only query the DPDB for results from incidents that happened at that MTF. 

MTFs can request that their oversight agency query the DPDB for relevant information on 

a physician related to incidents at other MTFs. However, due to current design limitations 

within CCQAS, each service can only query the DPDB for its own service-specific 

information.
 

Page 18 GAO-12-31 DOD Credentialing and Privileging

DOD lacks a process to address inconsistencies in credentialing and 

privileging requirements and achieve its stated goal of standardizing 

physician credentialing and privileging processes across the MHS. The 

Assistant Secretary of Defense for Health Affairs has the responsibility to 

oversee the military services’ implementation of physician credentialing 

and privileging requirements and to ensure consistent application of those 

requirements across the MHS. Moreover, the senior DOD official 

responsible for credentialing and privileging told us that DOD expects the 

military services’ requirements to be consistent with DOD’s and confirmed 

that, moving forward, DOD’s goal is to standardize credentialing and 

privileging across the MHS.

However, the senior DOD official responsible for credentialing and 

privileging also told us that DOD relies on the military services to ensure 

that their requirements are consistent with DOD’s requirements. The 

official acknowledged that DOD does not have a DOD-wide process to 

identify and address inconsistencies in requirements, either between 

DOD and the services, or among the services themselves. Without a 

DOD-level process, DOD cannot adequately assure that its requirements 

are being consistently applied across the MHS and that the military 

services are moving towards DOD’s stated goals and expectations for 

standardizing credentialing and privileging processes.

As of September 2011, DOD and two of the military services were 

revising their credentialing and privileging requirements, but there is no 

assurance that the inconsistencies we found among the military services 

will be brought in line with DOD’s requirements during this revision 

process.26

 

26Army and Navy are currently revising their credentialing and privileging requirements. 

Air Force published its revised requirements in August 2011.

In our discussions about ongoing efforts to revise credentialing 

and privileging requirements, the responsible DOD official told us that 

DOD has a process for coordinating revisions to DOD’s requirements with 

the military services’ central oversight agencies. The oversight agencies 

each have the opportunity to review and make comments on any changes 

to DOD requirements. However, there is no similar process for DOD to 

review and comment on any changes the military services make when 

revising their requirements. Additionally, DOD lacks a process to assure 

that the military services coordinate revisions to their physician 

credentialing and privileging requirements with each other. An official 

DOD Lacks a Process to 

Address Inconsistencies 

among DOD’s and the 

Military Services’ 

Physician Credentialing 

and Privileging 

Requirements
 

Page 19 GAO-12-31 DOD Credentialing and Privileging

from one military service’s oversight agency told us that they have 

discussed some specific military-service-level revisions with the other 

oversight agencies. However, there is no systematic, DOD-established 

process to coordinate all of their revisions. Absent a process for 

coordinating revisions to the military services’ requirements, DOD cannot 

ensure that credentialing and privileging requirements are consistent 

across the MHS.

Based on our review of 150 credentials files at the five Army MTFs we 

selected for our review, we found that none of the five Army MTFs fully 

complied with certain Army physician credentialing and privileging 

requirements. Specifically, we found that the selected MTFs did not fully 

comply with the Army’s requirement to primary source verify all state 

medical licenses at the time of privileging and at renewal. Also, we found 

that documentation intended to support a physician’s clinical competence 

often did not include the information required by the Army to document a 

physician’s competence. Finally, while selected MTFs complied with 

Army’s requirement to query the NPDB, it was not possible to tell if they 

complied with the Army’s requirement to account for all periods of time 

since the physician’s medical degree was obtained.

The Army requires that credentials staff at MTFs primary source verify all 

state medical licenses ever held by a physician, even those which are no 

longer active or have expired, at the time of privileging.27

During our review of credentials files we found that credentials staff at the 

five selected Army MTFs were not consistently documenting primary 

source verification of all state medical licenses as required by the Army 

regulation. For 34 of 150 credentials files we reviewed, we found that the 

MTFs’ credentials staff had not documented primary source verification of 

all state medical licenses a physician ever held at the time of privileging. 

Furthermore, the 

Army requires that MTFs primary source verify any state medical license 

that a physician holds at the time of renewal of the license—at such time 

the physician may elect to either renew the license or allow it to expire.

 

27State medical licenses can have one of several different statuses, including active, 

expired, valid, and unrestricted. During our review we did not see any licenses with a 

status other than active, inactive, or expired. We reported licenses that were either 

inactive or expired as “expired.” 

Selected Army MTFs 

Did Not Fully Comply 

with Certain Army 

Physician 

Credentialing and 

Privileging 

Requirements 

Selected MTFs Did Not 

Fully Comply with Army 

Requirements to 

Document Primary Source 

Verification of All State 

Medical Licenses
 

Page 20 GAO-12-31 DOD Credentialing and Privileging

Further, for 7 of these 34 credentials files, MTFs’ credentials staff had not 

documented primary source verification of the physician’s only active 

state medical license at the time of privileging. However, after the 

physician was granted privileges—but before our site visit—the MTFs’ 

credentials staff had discovered the error and performed and documented 

the primary source verification for 5 of these 7 credentials files.

In addition, we found examples of credentials files in which the MTFs’ 

credentials staff had not documented primary source verification of each 

state medical license at the time that the physician either renewed the 

license or allowed it to expire, as required by the Army. Specifically, we 

found 28 credentials files in which the MTFs’ credentials staff had not 

promptly documented primary source verification at the time a physician’s 

license was scheduled to be renewed. For example, during our review of 

credentials files we found that a physician—last privileged in January 

2009—had a medical license that was scheduled to be renewed in 

December 2009.28

Without fully complying with Army’s requirement to primary source verify 

all state medical licenses a physician has ever held, MTF staff who 

approve physician’s credentials and privileges cannot ensure that they 

are aware of all restrictions on, actions taken against, or changes in 

status of a physician’s medical licenses for practice-related reasons. Full 

compliance with this requirement, both at the time of privileging and at the 

time that medical licenses are renewed, is important because physicians 

may have not disclosed all changes in the status of their licenses to the 

MTF. For example, we reviewed one credentials file in which the MTF’s 

credentials staff identified, in the process of primary source verifying the 

physician’s medical licenses, pending actions against the physician’s 

licenses that the physician had not disclosed.

At the time we conducted our site visit in September 

2010—10 months after the license’s expiration date—the credentials file 

did not contain documentation that the MTF’s credentials staff had 

verified with the primary source whether the physician had renewed that 

medical license or allowed it to expire.

 

28This was not the physician’s only state medical license, and this physician did have one 

current, active primary source verified license in their credentials file at the time we 

conducted our review. 
 

Page 21 GAO-12-31 DOD Credentialing and Privileging

We found that most of the 150 credentials files we reviewed at the five 

MTFs we selected contained required clinical competence documents—

two peer recommendations, performance assessments, and the 

associated provider activity file (PAF).29

Peer recommendations provide evidence of competence based on the 

documented assessment of a peer who has current, first-hand knowledge 

of the physician’s clinical competence. In 111 of 125 credentials files

However, during our review we 

found that these documents did not consistently contain information 

required by the Army regulation to fully document a physician’s clinical 

competence. We found that peer recommendations did not consistently 

contain required information to document they were from a peer with 

current, first-hand knowledge of the physician’s clinical competence, and 

that MTFs did not consistently document any follow-up conducted on peer 

recommendations as required. Also, we found that performance 

assessments did not consistently contain required data to support the 

assessment of the physician. Finally, we found that physicians’ PAFs did 

not consistently contain required data to evaluate performance and 

support the renewal of privileges.

30 we 

found that MTFs’ credentials staff had filed the two required peer 

recommendations in the physician’s credentials file.31

 

29MTFs maintain a PAF for each physician that should include information related to their 

ongoing performance. The PAF is a paper file, and information contained within it is not 

routinely shared with other MTFs, even if the physician is changing permanent duty 

stations.

However, peer 

recommendations we reviewed often did not contain sufficient information 

for us to determine if the recommendation met the Army’s requirement to 

be from an individual with current, first-hand knowledge of the physician’s 

clinical competence. Of the 111 credentials files that contained the 

required number of peer recommendations, 51 included at least one 

recommendation that did not contain sufficient information for us to 

determine if the individual who wrote the recommendation was a peer 

with current, first-hand knowledge of the physician’s clinical 

30Because 25 of the 150 credentials files we reviewed were for physicians who were on 

ICTB, and therefore were not required to have peer recommendations, only 125 

credentials files required peer recommendations. 

31The credentials files we reviewed did not contain sufficient documentation for us to 

determine if MTFs were routinely primary source verifying peer recommendations. 

Selected MTFs Did Not 

Fully Comply with Army 

Requirements to 

Document Physician 

Clinical Competence

Peer Recommendations Lacked 

Sufficient Information and 

MTFs Did Not Consistently 

Document Follow-up
 

Page 22 GAO-12-31 DOD Credentialing and Privileging

competence.32

Four of the five MTFs we selected had a standard peer recommendation 

form that prompted the individual writing the recommendation to provide 

information detailing that individual’s relationship with the physician and 

what period of time the individual had known the physician. The 

remaining MTF’s peer recommendation form did not specifically ask for 

this information. Regardless of the peer recommendation form an MTF 

used, we found that individuals who submitted the recommendations 

were not consistently providing information related to the nature and 

length of their relationship with the physician. Credentials staff at some of 

the selected MTFs told us that it is the credentials staff responsibility to 

review the peer recommendations to determine if they are from someone 

with current, first-hand knowledge of the physician.

Furthermore, we found 4 credentials files where one or 

more of the individuals completing one of the two required peer 

recommendations clearly indicated they did not have current, first-hand 

knowledge of the physician’s clinical competence.

Credentials staff told us that for physicians renewing their privileges, they 

often rely on their knowledge of the MTFs’ medical staff to determine if 

the recommendation was written by a peer. For physicians who are being 

privileged for the first time at the MTF, credentials staff told us they look 

for information in the recommendation, such as the person’s title or 

signature line, to determine if the recommendation was written by a peer. 

Without this information clearly documented in the credentials file, an 

MTF official responsible for reviewing a physician’s application for 

privileges would not have reasonable assurance that a peer 

recommendation was written by an individual qualified to attest to the 

physician’s clinical competence.

While Army regulation does not require MTF staff to follow up on a peer 

recommendation, it does require that any follow-up conducted on a peer 

recommendation be documented. Specifically, Army regulation states 

that, “[a]nnotated records of each contact made with all personal and 

professional references will be maintained, to include names of all parties 

 

32We found some examples among these 51 files in which one or more recommendations 

was written by a physician who appeared to be practicing at the same MTF as the 

physician whose file we were reviewing. However, this was not always indicated in the 

recommendation itself, and we did not systematically check to see if recommendations 

were written by a physician working at the MTF we selected or another MTF. 
 

Page 23 GAO-12-31 DOD Credentialing and Privileging

to the call, the date, and a summary of the conversation.”33

Even when MTF staff told us that they had conducted follow-up on peer 

recommendations, they did not consistently document that follow-up in 

the credentials files we reviewed. Specifically, we found five instances 

where MTF staff confirmed that they had conducted follow-up on a peer 

recommendation that raised questions about a physician, but the 

credentials file did not contain documentation of that follow-up. We found 

other examples of recommendations that included the types of comments 

that department chiefs told us they would follow up on—such as “might do 

well in supervised group setting. Call me”—but did not always find followup documented in those credentials files. Some chiefs acknowledged that 

when something prompted them to follow up on a peer recommendation 

they would not routinely document these conversations in the credentials 

file because they thought credentials staff were including this detail in the 

credentials committee meeting minutes. Some department chiefs told us 

that they discuss follow-up on peer recommendations with the MTF’s 

credentials committee prior to making a decision on whether or not to 

recommend a physician for privileges. As a result, they told us the 

documentation of follow-up on peer recommendations would be captured 

in the meeting minutes of the MTF’s credentials committee. However, 

when we spoke with credentials staff responsible for creating meeting 

minutes, they told us the minutes would not usually include that level of 

detail on a physician, unless the physician’s privileges were adversely 

affected. This was generally consistent with what we observed when we 

reviewed the credentials committee meeting minutes for the MTFs we 

selected. (See Fig. 2 which illustrates an example of the type of peer 

recommendation that department chiefs told us would prompt them to 

Department 

chiefs, who were conducting most of the follow-up on peer 

recommendations at MTFs, told us that under various circumstances they 

would contact an individual to follow up on a peer recommendation. For 

example, some told us they would only follow up for physicians who were 

contractors or civilians who were new to the MTF. Others said they would 

follow up only if something in the recommendation raised questions about 

a physician. Department chiefs often said that reviewing a 

recommendation requires reading “between the lines” to determine 

whether follow-up is required because people are hesitant to include 

negative information in peer recommendations.

 

33Army Regulation 40-68, 8-8, b., p.52.
 

Page 24 GAO-12-31 DOD Credentialing and Privileging

follow up because the baseline for recommendations is excellent and 

anything else would raise concerns.)

Figure 2: Example of a Peer Recommendation that Could Raise Concern 

Note: Three of the five MTFs we selected for our review used an MTF-specific peer recommendation 

form that included this table.
 

Page 25 GAO-12-31 DOD Credentialing and Privileging

The Army requires a physician’s department chief to complete two 

performance assessments—Army Form 5374 Performance Assessment 

and Army Form 5441 Evaluation of Clinical Privileges—at the time a 

physician renews their privileges in order to document the physician’s 

clinical competence. Eighty-three of 104 credentials files34 we reviewed 

contained both required performance assessments at the time of 

privileging, but 21 were missing documentation of either one or both of 

the performance assessments.35

During our review of completed Form 5374s we found that MTFs’ 

department chiefs did not consistently include data to support 

performance assessments of physicians as required by the Army 

regulation. The Form 5374 provides for a department chief to assess a 

physician in various performance categories. While not all categories are 

relevant for each physician; for example, a family practice physician 

would not usually be assessed under “surgical case review;” there are 

other performance categories included on the Form 5374, such as 

“records review” that are applicable to all physicians. However, during our 

review we found that assessments were sometimes missing from relevant 

performance categories, such as “surgical case review” for a surgeon or 

another physician who has performed surgeries during the review period. 

Figure 3 shows a range of examples that illustrate the types of 

assessments we found in the Form 5374s during our file review. The first 

example illustrates a Form 5374 with data to support the assessment for 

relevant performance categories, while the second example 

demonstrates a Form 5374 that has no data to support the assessment 

for relevant performance categories. The third example shows a Form 

5374 that has no assessments or data for any performance categories.

When asked about missing performance 

assessments, MTFs’ credentials staff told us that it was sometimes 

challenging to obtain performance assessments for physicians who had 

been deployed or had been temporarily assigned to work at another MTF, 

although we found credentials files missing performance assessments 

where the physician was neither deployed nor returning from a temporary 

assignment.

 

34Forty-six of the 150 files we reviewed were either for a physician on ICTB from another 

MTF or for a physician who was new to the military, and therefore were not required to 

have the Army Forms 5374 and 5441. 

35Of the 21 files that were missing performance assessments, 14 were missing both 

assessments, and 7 were missing either the Form 5374 or the Form 5441. 

Data Were Not Consistently 

Available to Support Physician 

Performance Assessments 
 

Page 26 GAO-12-31 DOD Credentialing and Privileging

Figure 3: Examples of Data Provided in Form 5374s at Army MTFs GAO Selected for its Review

Note: Text in the figure represents information from performance assessments we reviewed during 

our site visits to the five Army MTFs we selected for our review. Text reflects the actual information 

included in performance assessments, and has not been edited by GAO. Not all categories are 

relevant for each physician, for example a family practice physician would not usually be assessed 

under “surgical case review.” Other performance categories included on the Form 5374, such as 

“records review,” are applicable to all physicians.
 

Page 27 GAO-12-31 DOD Credentialing and Privileging

Further, even when MTFs included specific text in their Form 5374 to 

prompt the department chief to include data, department chiefs did not 

consistently provide data to support their assessments. Four of the five 

MTFs we selected had included standardized text in the Form 5374 to 

prompt for performance data or yes/no checkmarks. Two MTFs modified 

their Form 5374 to prompt for data to support the assessment (for 

example, X records reviewed, Y met the standard); however, we found 

that department chiefs did not consistently provide this information. In 

instances where the form had been modified to prompt for yes/no check 

marks or was not modified with standardized text, we found that 

department chiefs did not consistently provide data to support their 

assessment of a physician.

Army regulation also requires that each MTF have a mechanism in place 

to collect and analyze individual performance data, from a variety of 

sources, to assess a physician’s competence. Department chiefs we 

interviewed consistently told us that they were collecting data on a 

physician’s performance, but they were not always compiling and 

analyzing the available data when completing the Form 5374. In addition, 

several department chiefs at MTFs we selected told us that their MTF 

lacked a systematic process—such as a software system or personnel 

resources—for collecting and analyzing performance data. Absent such a 

process, department chiefs told us that they often based performance 

assessments on their personal knowledge of a physician’s clinical 

competence. As a result, several department chiefs described the 

process of filling out the performance evaluation forms as a “pencilpushing exercise.” 

Army requires MTFs to maintain a PAF that should contain various types 

of clinical data, including metric performance data to be used to profile a 

physician’s clinical practice, to periodically reevaluate performance, and 

assist with the renewal of privileges. At the five Army MTFs we selected, 

we found that 134 of 150 credentials files36

 

36Ten of the 16 credentials files that did not have an associated PAF were for physicians 

on ICTB. The Army requires that a PAF be maintained for all privileged physicians, but 

does not specify that a “receiving” MTF for a physician on ICTB do so.

had an associated PAF. 

However, we found limited data in PAFs that related to the physician’s 

performance. Specifically, in 103 of 150 credentials files we reviewed, we 

found that the MTF had not documented data in an associated PAF to 

support physician performance assessments.

Provider Activity Files Lacked 

Documentation of Ongoing 

Performance 
 

Page 28 GAO-12-31 DOD Credentialing and Privileging

Credentials staff at most MTFs we selected told us that performance data

were maintained by individual departments, but acknowledged that data 

were not being consistently submitted to credentials staff to be included in 

the PAF. We did see some instances where MTFs had stored some 

practice data on the physician in the PAF such as results from 

departmental reviews of a physician’s medical charts. Some PAFs 

contained other information about a physician’s practice such as the 

number of patients a physician treated, letters from patients, or results 

from patient satisfaction surveys. Within the PAFs we found that did not 

contain data to support the physician’s performance assessment, we saw 

examples where the PAF was empty or the MTF had used the PAF to 

store nonperformance-related information such as administrative 

documents (i.e., email exchanges between credentials staff and the 

physician, or copies of the physician’s performance assessments).

Without required information in the peer recommendations and the PAF, 

as well as information in the Form 5374 to support performance 

assessments, MTFs lack assurance that they are granting privileges 

based on complete evidence of a physician’s clinical competence. 

Furthermore, absent a systematic process for compiling and analyzing 

performance data, MTFs lack assurance that they are granting privileges 

to physicians based on documented and analyzed performance data as 

opposed to anecdotal information about physician performance.

We found that credentials staff at the five Army MTFs we selected for our 

review were usually documenting information related to a physician’s 

practice history found in the NPDB. However, we found that credentials 

staff were not complying with Army’s requirement that the physician’s 

curriculum vitae (CV) account for all periods of time since the physician 

graduated from medical school.37

We found that credentials staff at the Army MTFs we selected 

documented their queries of the NPDB at the time of privileging—as 

required by the Army regulation—in 147 of 150 credentials files. One of 

the 3 credentials files we reviewed that did not contain documentation of 

current NPDB queries at the time of privileging was for a physician on 

 

37A curriculum vitae provides a short account of an individual’s career and qualifications, 

similar to a resume.

Selected Army MTFs Did 

Not Fully Comply with 

Requirements to 

Document Physician 

Practice History
 

Page 29 GAO-12-31 DOD Credentialing and Privileging

ICTB to an MTF in our sample. While the receiving MTF we selected 

usually queried the NPDB before privileging physicians on ICTB, Army 

regulation does not specify that they do so.38

The Army requires that a physician’s credentials file contain a CV to 

account for all periods of time subsequent to obtaining their medical 

degree, in order to document the physician’s complete practice history. At 

the five Army MTFs we selected, we found that 115 of 125 credentials 

files had the required CV.39

We were unable to determine how well the five selected MTFs were 

complying with the requirement to account for all periods of time since 

obtaining a medical degree in the CV because of insufficient information 

in the credentials files we reviewed. In 63 of the 115 credentials files that 

included the required CVs, the CV did not include both the months and 

the years a physician had worked at a previous location. While the Army 

does not specifically require CVs to contain both months and years, 

credentials staff acknowledged that they would need start and end 

dates—including both month and year—to identify if all periods of time 

were accounted for since the medical degree was obtained. Furthermore, 

even when CVs contained both months and years, they did not always 

account for all periods of time. Although not specified in Army regulation, 

the responsible Army Medical Command official said that if there were 

periods of time that were not accounted for in the CV, they would expect 

explanations for those periods of time to be documented in the 

credentials files. However, we found that credentials files did not 

consistently contain documents explaining unaccounted for periods of 

time. Without this information clearly documented in the credentials file, 

an MTF official responsible for reviewing a physician’s application for 

When asked about credentials files that were 

missing CVs, credentials staff sometimes said they had requested them 

but had not received them. Credentials staff at two MTFs said that they 

would not necessarily hold a physician’s application back from credentials 

committee review because it was missing a CV.

 

38The ICTB sent by the permanent duty station includes a section on relevant information 

found in the NPDB which the receiving MTF can refer to when making a decision to 

privilege a physician. 

39Twenty-five of the 150 credentials files we reviewed were for physicians who were on 

ICTB and therefore were not required to have a CV. 
 

Page 30 GAO-12-31 DOD Credentialing and Privileging

privileges would not have reasonable assurance that all unaccounted for 

periods of time had been identified and explained.

Army oversight and physician credentialing and privileging requirements 

were not sufficient to assure that MTFs fully complied with existing 

requirements or completely documented information needed to support 

credentialing and privileging decisions. Specifically, Army Medical 

Command’s oversight of individual MTFs’ reviews of physicians’ 

applications for privileges was insufficient to identify the instances of 

noncompliance and incomplete documentation that we observed during 

our review of credentials files at five selected Army MTFs. In particular, 

Army Medical Command’s oversight did not include a process for 

conducting reviews of individual MTFs’ credentials files. In addition, Army 

physician credentialing and privileging requirements were insufficient in 

some respects. Certain requirements do not clearly delineate 

responsibilities and procedures for documenting complete information in 

order to comply with the requirement. Additionally, Army has not 

established requirements for documenting certain types of information 

that are needed to support credentialing and privileging decisions.

Army Medical Command oversight was not sufficient to assure that 

individual MTFs fully complied with Army physician credentialing and 

privileging requirements and documented complete information needed to 

support credentialing and privileging decisions. Under Army regulation, 

Army Medical Command is responsible for conducting broad oversight of 

the implementation of credentialing and privileging requirements at MTFs. 

In addition to Army regulation, the Standards for Internal Control in the 

Federal Government states that an organization should provide 

reasonable assurance of compliance with applicable laws and 

regulations.40 These standards, along with the Internal Control 

Management and Evaluation Tool, also state that an organization should 

record information and communicate it to management and others who 

need it in a form and within a time frame that enables them to carry out 

their responsibilities efficiently and effectively.41

 

40See 

However, we found that 

Army Medical Command’s oversight lacked a process for reviewing 

GAO/AIMD-00-21.3.1, p. 6.

41See GAO/AIMD-00-21.3.1, p.20, and GAO-01-1008G, p. 53.

Army Oversight and 

Physician 

Credentialing and 

Privileging 

Requirements Were 

Insufficient to Assure 

that MTFs Fully 

Complied and 

Documented 

Complete Information

Army Medical Command 

Oversight Was Insufficient 

to Assure that MTFs Fully 

Complied and 

Documented Complete 

Information 
 

Page 31 GAO-12-31 DOD Credentialing and Privileging

individual MTFs’ credentials files to identify instances of noncompliance 

or incomplete documentation.

As noted earlier in this report, the five Army MTFs we selected for our 

review did not fully comply with established Army physician credentialing 

and privileging requirements or document complete information in the 

following areas:

Documentation of primary source verification of state medical 

licenses. Credentials files did not consistently document primary 

source verification of all physician state medical licenses at the time of 

privileging or at the time the licenses were scheduled to be renewed.

Documentation of clinical competence. Credentials files did not 

consistently include required peer recommendations or performance 

assessments, or associated PAFs, to support clinical competence. 

Additionally peer recommendations, performance assessments, and 

PAFs did not consistently include required information and credentials 

files did not consistently include required documentation of any followup conducted on peer recommendations. Further, MTFs lacked a 

mechanism for collecting and analyzing performance data.

Documentation of practice history. Credentials files did not 

consistently include a CV to account for all periods of time subsequent 

to the medical degree. When included, physician CVs did not 

consistently include sufficient information to determine if they met 

Army’s requirement to account for all periods of time since obtaining 

the medical degree.

At the five MTFs we selected, the credentials committee chairperson and 

the MTF commander had reviewed the application for privileges for each 

physician in our sample; but those reviews did not prevent the instances 

of noncompliance and incomplete documentation discussed above. 

Credentials committee chairpersons we interviewed said they often focus 

their reviews on looking for potentially negative information in the file, 

such as negative peer recommendations. Credentials committee 

chairpersons also said they often rely on credentials staff to ensure that 

files contain all required documents before they reach the credentials 

committee and they rely on department chiefs to raise any concerns that 

surfaced during their review of the application. Ultimately, Army regulation 

assigns MTF commanders the final responsibility for ensuring systematic 

review of credentials and competence for all physicians at their respective 

MTFs and ensuring compliance with applicable requirements. However, 
 

Page 32 GAO-12-31 DOD Credentialing and Privileging

MTF commanders had granted privileges based on credentials files that 

did not fully comply with Army physician credentialing and privileging 

requirements or contain complete documentation of information needed 

to support credentialing and privileging decisions.

Although we identified these instances of noncompliance and incomplete 

documentation through reviews of credentials files, we found that Army 

Medical Command’s oversight of physician credentialing and privileging 

did not include a routine process for conducting reviews of individual 

MTFs’ credentials files. The responsible Army Medical Command official 

told us that Army’s regional medical commands began conducting some 

visits to individual MTFs at the beginning of fiscal year 2011.42 However, 

these visits—which may include reviews of the MTFs’ credentials files in 

preparation for the MTFs’ triennial review by The Joint Commission43

The responsible Army Medical Command official said that Army Medical 

Command’s oversight consisted mainly of running CCQAS data reports, 

which we found was not sufficient to assure that MTFs fully complied with 

Army physician credentialing and privileging requirements or completely 

documented information needed to support credentialing and privileging 

decisions. These reports focused primarily on identifying potential lapses 

in MTFs’ credentials verification processes and on the completeness of 

information MTFs enter into CCQAS. Specifically, the Army Medical 

Command official reported running periodic CCQAS reports on metrics 

such as the number of unlicensed providers or the number of electronic 

applications at an MTF. However, these CCQAS reports did not provide 

complete information about MTFs’ compliance with physician 

—

are not focused on credentialing and privileging. In addition, the regional 

commands do not currently have a process for routinely reporting the 

results of any reviews of credentials files they may perform to Army 

Medical Command. However, the Army Medical Command official told us 

that they hold regular teleconferences with MTF staff and said that staff 

would discuss any issues found during regional command reviews on 

these teleconferences.

 

42Previously, the Army Medical Command Inspector General conducted quality 

inspections at a sample of individual MTFs. These inspections sometimes included 

reviews of MTF’s credentials files, but were not specific to credentialing and privileging.

43Credentialing and privileging requirements may be one element of the accreditation 

reviews conducted by The Joint Commission, though not all reviews include this element.
 

Page 33 GAO-12-31 DOD Credentialing and Privileging

credentialing and privileging requirements, as evidenced by the instances 

of noncompliance that we observed, and are discussed above. 

Additionally, CCQAS reports did not provide Army Medical Command 

information about whether MTFs were documenting complete information 

needed to support credentialing and privileging decisions. For example, 

Army Medical Command lacked information about the following types of 

incomplete documentation in credentials files, which we noted earlier in 

this report:

Documenting the source of peer recommendations. Peer 

recommendations we reviewed did not always include sufficient 

information to determine if they met Army’s requirement to be from 

someone with current, first-hand knowledge of the physician’s 

competence. Army Medical Command officials said they thought most 

MTFs’ peer recommendation forms would prompt for information 

about the peer’s relationship with the physician—such as how long 

they have known them and for what period of time. However, Army 

Medical Command was not aware that even when MTFs’ forms 

prompted for this information, the source of peer recommendations 

was not always documented.

Documenting data in performance assessments. Performance 

assessments we reviewed did not consistently contain performance 

data needed to support the assessments. The responsible Army 

Medical Command official told us that Army expects performance 

assessments to include supporting data, as stated in Army regulation. 

This official also said that the use of yes/no checkmarks alone in 

these assessments would not be sufficient. However, Army Medical 

Command was not aware that some MTFs (including two of the five 

MTFs we selected) have modified the Form 5374 with standardized 

text which prompted only for checkmarks. They were also unaware 

that even when MTFs’ forms prompted for data, they were not always 

included.

A mechanism for collecting and analyzing performance data. 

MTF staff expressed a need for a mechanism to collect and analyze 

performance data to better support performance assessments. We 

found that four of the five MTFs we selected were taking steps to 

develop, or invest in, software to help address this need. These 

MTFs—and in one case, two different departments within one MTF—
 

Page 34 GAO-12-31 DOD Credentialing and Privileging

were each investing resources in systems that collect similar 

information.44 While the responsible Army Medical Command official 

acknowledged that Army MTFs face challenges meeting the 

requirement and that some had developed “home grown” systems, 

this official said that Army Medical Command was not coordinating 

these efforts.45

Given our findings that Army Medical Command lacks a routine process 

for conducting reviews of individual MTFs’ credentials files to identify 

noncompliance and incomplete documentation, we interviewed Navy and 

Air Force officials about their oversight of physician credentialing and 

privileging. Navy and Air Force officials told us that their oversight 

agencies also do not conduct their own routine reviews of individual 

MTFs’ credentials files. Both services reported regional or MTF-level 

reviews similar to Army’s but acknowledged that these reviews do not 

focus on credentialing and privileging, may not occur on a regular basis, 

and the results are not formally reported to BUMED and AFMOA. 

Additionally, Navy and Air Force officials told us that, like Army, they use 

CCQAS data reports as their primary oversight mechanism.

Army Medical Command’s current oversight process 

did not facilitate an evaluation of the potential benefits of a more 

systematic process to help MTFs meet Army’s performance data 

requirement and avoid potential duplication and inefficient use of 

resources resulting from these MTFs’ efforts.

46

 

44In June 2011, staff at one MTF told us that they had been working to replace the system 

they had developed locally by implementing a software program recommended by their 

regional medical command. However, in September 2011, staff at this MTF told us that 

the MTF had decided not to implement the new system because they lacked the 

resources and support needed. They also told us that they had not found any other MTFs 

in the region who had successfully implemented the system. 

The 

responsible Navy official acknowledged that they would not be able to 

identify MTF-level compliance issues without conducting reviews of 

credentials files.

45The responsible Navy and Air Force officials told us that some Navy and Air Force MTFs 

have developed their own data systems as well. The responsible Navy official told us that 

there is a need for a system to compile performance data across the MHS and it would be 

helpful if DOD were to implement an MHS-wide solution. The responsible DOD official 

said that they were not aware of individual MTFs’ efforts to develop data systems, but 

acknowledged that there may be a role for DOD to coordinate MTFs’ efforts.

46Navy and Air Force officials also reported that they conduct oversight through training, 

regular teleconferences, and their daily interactions with MTF staff to address questions 

that arise.
 

Page 35 GAO-12-31 DOD Credentialing and Privileging

We found that Army physician credentialing and privileging requirements 

were insufficient to assure that MTFs fully complied and documented 

complete information needed to support credentialing and privileging 

decisions. As noted, internal control standards state that an organization 

should provide reasonable assurance of compliance and should record 

information and communicate it efficiently and effectively.47

Certain Army requirements do not clearly delineate responsibilities and 

procedures for documenting complete information in order to comply with 

the requirement. Specifically, a lack of clarity in the following Army 

requirements contributed to noncompliance:

However, we 

found that unclear requirements contributed to the instances of 

noncompliance and incomplete documentation we observed at the five 

MTFs we selected. Additionally, Army has not established requirements 

for documenting certain types of information needed to support 

credentialing and privileging decisions. Army Medical Command officials 

acknowledged that, in some cases, their expectations for documenting 

this information were not explicit in existing Army regulation.

Documenting follow-up on peer recommendations. Army 

regulation requires documentation of any follow-up conducted on

peer recommendations, but does not specify who is responsible for 

documenting follow-up or where it should be documented. As a 

result, MTFs did not consistently meet Army’s requirement to 

document follow-up. As noted earlier in this report, department chiefs 

we interviewed routinely told us that discussion of follow-up on peer 

recommendations that occurred during a credentials committee 

meeting would be documented in the meeting minutes. However, 

credentials staff told us those minutes would not usually contain that 

level of detail. The responsible Army Medical Command official told 

us that they expect MTFs to document follow-up on peer 

recommendations. However, when asked who should document this 

information and where it should be documented, this official did not 

have clear expectations.

 

47See GAO/AIMD-00-21.3.1, p.6 and p.20, and GAO-01-1008G, p.53.

Army Physician 

Credentialing and 

Privileging Requirements 

Were Insufficient to Assure 

MTFs Fully Complied and 

Documented Complete 

Information 

Certain Army Requirements 

Unclear 
 

Page 36 GAO-12-31 DOD Credentialing and Privileging

Accounting for all periods of time in physician CVs. Army 

regulation requires physician CVs to account for all periods of time 

subsequent to the medical degree in order to document the 

physician’s complete practice history, but does not specify what 

information needs to be documented to meet this requirement. 

Specifically, Army regulation does not require CVs to include both 

months and years for previously held positions, though the 

responsible Army Medical Command official said this would be 

necessary to identify any gaps in practice history. While credentials 

staff agreed that they would need months and years in order to 

identify gaps, they acknowledged they were not routinely looking for 

this information in the CV. Army regulation also does not specifically 

require MTFs to document explanations of any gaps in the CV, 

though the Army official said they should. Credentials staff at some 

MTFs said that gaps should be explained somewhere in the 

credentials file; however, we did not consistently see this in 

credentials files we reviewed.

Army has not established requirements for documenting certain types of 

information that are needed to support credentialing and privileging 

decisions; specifically, significant events that occurred during an MTF’s 

review of a physician’s application for privileges or information that may 

be relevant from the DPDB.

Documenting significant events. Current Army regulation does not 

specifically require MTFs to document significant events—such as the 

MTF’s consideration of concerns about a physician raised in 

performance assessments, NPDB queries, and other clinical 

competence and practice history documents—that occurred during 

their review of a physician’s application for privileges.48 Nevertheless, 

Army Medical Command officials said that they expect MTFs to 

document follow-up on some issues raised in the credentials file. For 

example, Army Medical Command officials said that they would 

expect documentation of an MTF’s consideration of concerns raised in 

a physician’s CV, but would not necessarily expect documentation of 

 

48The internal control standards specifically identify significant events as a type of 

information that should be clearly documented and readily available for examination 

(GAO/AIMD-00-21.3.1, p.17). 

Army Has Not Established 

Requirements for Documenting 

Certain Types of Information
 

Page 37 GAO-12-31 DOD Credentialing and Privileging

an MTF’s consideration of NPDB query results.49 The responsible 

Army Medical Command official acknowledged that their 

expectations may not be consistent with what MTFs are doing.50

Documenting relevant information from the DPDB. Unlike 

DOD, Army regulation does not specifically require MTFs to query 

the DPDB for each physician. As a result, the Army MTFs we 

selected were consistently not querying the DPDB. Additionally, 

Army has not established requirements for documenting risk 

management information—such as reviews of malpractice claims 

and potentially compensable events—from the DPDB or specified 

which types of information should be considered relevant. 

However, the responsible Army Medical Command official said 

they expect MTFs to document risk management information from 

the DPDB that may be relevant to credentialing and privileging in 

the credentials file. For example, the Army official said MTFs are 

expected to document information from the DPDB in a physician’s 

credentials file if the MTF determines that the physician did not 

meet the standard of care. These officials acknowledged that this 

expectation is not explicit in Army regulation.

Despite Army Medical Command’s expectations, the MTFs we 

selected were not always documenting this information.

51

In addition to the lack of requirements that MTFs query the DPDB 

and document relevant risk management information in 

credentials files, Army has not addressed access limitations to 

information in the DPDB. The responsible Army Medical 

Command official stated that the DPDB does not allow MTFs to 

 

49The responsible Navy, Air Force, and DOD officials all said that they would expect MTFs 

to document their consideration of NPDB query results.

50Although the DOD regulation does not specifically require documentation of significant 

events, the responsible DOD official expressed concern that this may not be happening 

routinely. The responsible Navy and Air Force officials agreed that MTFs should document 

follow-up on concerns raised in the credentials file. The responsible Air Force official 

acknowledged that this expectation is not explicit in Air Force regulation.

51The responsible Navy officials said that they only expect MTFs to document risk 

management information from the DPDB if it indicates a concern. These officials said this 

might occur if the MTF determines that the physician did not meet the standard of care, or 

if there is a concerning pattern of incidents. The responsible Air Force official said they 

expect MTFs to document risk management information in the credentials file, regardless 

of the MTF’s standard of care determination.
 

Page 38 GAO-12-31 DOD Credentialing and Privileging

query for information entered by another MTF.52

The lack of an Army requirement to query the DPDB, or obtain 

and document relevant information from risk management staff in 

the credentials file, combined with DPDB access limitations, 

contributed to MTFs not routinely obtaining relevant information 

from the DPDB. As a result some credentials files we reviewed 

lacked documentation of key information that DOD and Army have 

deemed important for MTF staff to make fully informed decisions 

on physicians’ competence. Specifically, during our review of the 

DPDB for physicians in our sample, we identified nine physicians 

with risk management information in the DPDB that was not 

documented in the physicians’ credentials files; for example, this 

information may be documented in physician disclosure forms, 

NPDB query results, or performance assessments. For eight of 

the nine physicians, the DPDB indicated that either the MTF’s 

review determined that the physician had met the standard of care 

or the MTF’s review was still pending at the time the physician 

was privileged. For one physician, the MTF had determined that 

the physician did not meet the standard of care. When we 

interviewed the credentials committee chairperson at that MTF, 

the chairperson told us that they were not aware of the review and 

that it should have been documented in the credentials file.

Moreover, most 

credentials staff we interviewed said that they did not have access 

to the DPDB itself and would have to request available information 

from risk management staff. However, credentials staff 

acknowledged that they were not requesting this information.

 

52The responsible Navy official said that Navy MTFs do not query the DPDB due to 

access limitations. These officials said that Navy has developed a form that can be used 

to document information from the DPDB that is considered relevant and cannot be found 

elsewhere in the credentials file. The responsible Air Force official said that Air Force 

MTFs are required to routinely submit requests for DPDB queries to AFMOA as part of the 

reprivileging process. This official also said that some Air Force MTFs are routing the 

performance assessment form to the MTF’s risk management staff at the time of 

privileging and asking them to include any relevant information from the DPDB. The 

responsible Army, Navy, Air Force, and DOD officials told us that planned updates to 

CCQAS by 2013 should help address MTF staffs’ access to information in the DPDB; 

however, their expectations for how the new feature would operate, including what 

information would be available and under what circumstances, varied.
 

Page 39 GAO-12-31 DOD Credentialing and Privileging

Physician credentialing and privileging requirements are central to DOD’s 

efforts to ensure that all physicians who work in the MHS are competent 

to provide care to servicemembers and their families. To achieve this, 

DOD and the military services have established requirements for how 

their MTFs validate and review each physician’s credentials, clinical 

competence, and practice history. However, the inconsistencies that we 

identified between the military services’ and DOD’s requirements create 

implementation and compliance challenges for MTFs, and make it 

inherently more difficult for DOD to ensure that the requirements are 

implemented consistently across the MHS. In addition, inconsistencies 

across the military services themselves create challenges for ensuring 

that all requirements are met for physicians from one service who are 

working at an MTF managed by another service and thus subject to 

different requirements. Without a DOD-wide process to identify and 

address such inconsistencies across DOD’s and the military services’ 

physician credentialing and privileging requirements and to coordinate all 

revisions to those requirements, DOD cannot ensure that the military 

services’ requirements are consistent across the MHS. As DOD moves 

towards a more standardized credentialing and privileging process, and 

MTFs are staffed with physicians from multiple military services, it is 

increasingly important that DOD ensure that physician credentialing and 

privileging requirements are consistent across the MHS.

At individual Army MTFs, complying with established credentialing and 

privileging requirements is integral to ensuring that physicians practicing 

at those MTFs are clinically competent and qualified in their areas of 

specialty. The findings from our review of a sample of credentials files at 

the five Army MTFs we selected for our review raise concerns about 

whether Army MTFs are systematically compiling, reviewing, and 

verifying all necessary information before granting a physician privileges. 

For example, some credentials files we reviewed lacked complete 

documentation to show that MTFs had primary source verified all of the 

physician’s state medical licenses, including seven instances involving a 

physician’s only active medical license. Additionally, documenting a 

physician’s clinical competence is a critical part of the credentialing and 

privileging processes, but some credentials files we reviewed did not 

include required peer recommendations, performance assessments, or 

PAFs. Even when credentials files contained these documents, the 

documents did not consistently contain required information, such as 

performance data to support assessments of a physician’s clinical 

competence. Finally, while MTFs routinely documented required NPDB 

queries, physician CVs often lacked sufficient information needed to 

document a complete physician practice history. Allowing these types of 

Conclusions 
 

Page 40 GAO-12-31 DOD Credentialing and Privileging

lapses to continue at MTFs raises the risk that physicians who may not be 

fully qualified or competent to practice in some areas are deemed fit to do 

so through flawed credentialing and privileging processes.

Our findings show that Army Medical Command’s oversight is not 

sufficient to ensure that individual MTFs fully comply with physician 

credentialing and privileging requirements, and that weaknesses in those 

requirements contribute to the types of noncompliance and incomplete 

documentation that we observed at five selected Army MTFs. Because 

Army Medical Command does not have an oversight process to review 

credentials files at individual MTFs, it does not have the information about 

noncompliance that it needs to hold MTF staff and commanders 

accountable to Army requirements, or to assess whether MTFs are 

documenting complete information needed to support credentialing and 

privileging decisions. Further, Army Medical Command had not assessed 

the potential to avoid duplication resulting from MTFs’ independent efforts 

to develop “home grown” systems to collect and analyze performance 

data to better support performance assessments. Our findings also 

identify weaknesses in existing Army physician credentialing and 

privileging requirements. For example, because Army requirements do 

not clearly delineate who is responsible for documenting follow-up on 

peer recommendations and where that documentation should be filed, 

MTFs were not consistently documenting follow-up. Additionally, Army 

has not established requirements for documenting certain types of 

information that are needed to support credentialing and privileging 

decisions. Although Army Medical Command expects MTFs to document 

some types of significant events—such as the MTF’s consideration of 

concerns raised in a physician’s CV—as well as relevant information from 

the DPDB, this is not explicitly required in current Army regulation. 

Without clear requirements to do so, MTFs were not consistently 

documenting these important types of information. Because of the 

frequent movement of physicians among Army MTFs and across the 

MHS, ensuring that MTFs completely document all information needed to 

support credentialing and privileging decisions is particularly important. 

The patterns of noncompliance and incomplete documentation we 

observed may also exist, beyond the Army MTFs we selected, at other 

services’ MTFs. Officials from Navy and Air Force oversight agencies 

acknowledged that, like the Army, they lack a process for reviewing 

individual MTFs’ credentials files, and that some of their documentation 

requirements are unclear. Consequently, weaknesses exist across the 

Army, Navy, and Air Force oversight agencies’ physician credentialing 

and privileging processes. If the weaknesses in these processes are not 

corrected, DOD and the military services cannot be certain that every 
 

Page 41 GAO-12-31 DOD Credentialing and Privileging

physician treating patients in the MHS is fully qualified and competent to 

practice the specific privileges they have been granted.

To help ensure that the military services’ requirements for physician 

credentialing and privileging are consistent across the MHS, we 

recommend that the Secretary of Defense direct the Assistant Secretary 

of Defense for Health Affairs and the Surgeons General of the military 

services to establish a DOD-wide process to:

• Identify and address existing inconsistencies between DOD’s and the 

military services’ physician credentialing and privileging requirements, 

including those inconsistencies we identified in this report, and

• Coordinate all current and future efforts to revise physician 

credentialing and privileging requirements.

To assure that information on a physician’s clinical competence and 

practice history is documented and available to support credentialing and 

privileging decisions by Army MTFs, we recommend that the Secretary of 

Defense direct the Assistant Secretary of Defense for Health Affairs and 

the Army Surgeon General to take the following five actions:

• Coordinate individual MTFs’ efforts to establish mechanisms to collect 

and analyze data to evaluate physician performance and support 

performance assessments.

• Clarify requirements for how MTFs document follow-up on peer 

recommendations, including who is responsible for documenting 

follow-up and where that documentation should be filed.

• Clarify requirements for the information that physicians need to 

provide in their CV so that MTFs can identify unaccounted for periods 

in practice history, as well as how MTFs should document 

explanations of any unaccounted for periods.

• Establish requirements for MTFs to document significant events that 

occur during the review of a credentials file, including which types of 

significant events should be documented, who is responsible for 

documenting significant events, and where that documentation should 

be filed.

Recommendations for 

Executive Action
 

Page 42 GAO-12-31 DOD Credentialing and Privileging

• Establish a process to ensure that relevant information from the 

DPDB is documented in the credentials file.

To assure that MTFs are fully complying with DOD’s and the military 

services’ requirements for physician credentialing and privileging and 

implementing these requirements appropriately, we recommend that the 

Secretary of Defense direct the Surgeons General of the military services 

to establish and implement an oversight process to conduct reviews of a 

sample of credentials files to identify and address areas of 

noncompliance and incomplete documentation.

We provided a draft of this report to DOD for comment and received a 

written response on November 30, 2011, which is reproduced in 

appendix II. DOD also provided technical comments which we have 

incorporated as appropriate. In its written comments, DOD concurred 

overall with our findings and conclusions and provided comments on our 

recommendations. While DOD’s comments suggested that DOD agreed 

with our recommendations, the comments do not provide sufficient detail 

for us to determine how fully the agency’s planned actions will address 

the intent of the recommendations. Additionally, in its comments, DOD did 

not establish time frames for any of the actions it identified to address our 

recommendations. The following discussion summarizes DOD’s response 

to our recommendations and our evaluation of the agency’s response.

DOD agreed to our first and second recommendations—to address 

inconsistencies across DOD’s and the military services’ requirements for 

physician credentialing and privileging and coordinate all efforts to revise 

requirements—and stated that it is updating its policies to establish “a 

single business process” for physician credentialing and privileging in the 

MHS and cited its ongoing revision to DOD Regulation 6025.13-R and/or 

planned updates to DOD’s CCQAS program. DOD noted that it will apply 

best practices that it has identified across the MHS to standardize 

physician credentialing and privileging requirements, eliminate 

inconsistencies, and clarify some aspects of the requirements. We agree 

that revising the DOD regulation and updating CCQAS may help promote 

a single business process for credentialing and privileging in the MHS. 

However, because DOD did not provide any detail on which 

inconsistencies it has identified and plans to address, it is not clear 

whether the revisions will fully address our recommendations. Moreover, 

DOD noted challenges in obtaining funding to support the redesign of 

CCQAS and did not establish any time frames for the redesign. Taken 

together this raises serious questions about when DOD will undertake this 

Agency Comments

and Our Evaluation
 

Page 43 GAO-12-31 DOD Credentialing and Privileging

effort, which is an integral part of the actions DOD described to address 

our recommendations. Addressing the inconsistencies that we identified 

in this report will require not only that DOD update its regulations and 

move forward with its redesign of CCQAS, but also that DOD establish a 

robust, DOD-wide process to ensure that each of the military services’ 

regulations are consistent with DOD’s. As part of this process DOD must 

ensure that any future revisions to DOD’s or the military services’ 

regulations do not create new inconsistencies. As long as there are 

inconsistencies between DOD’s written requirements and those of each 

military service, DOD will be constrained in its ability to ensure that each 

service is consistently applying DOD’s physician credentialing and 

privileging requirements.

In its response to our recommendation on coordinating the efforts of 

individual MTFs to establish mechanisms to collect and analyze physician 

performance data, DOD stated that requirements for “peer review”—a 

reference to departmental reviews of a physician’s medical charts—

should be standardized. That is not what we recommended. Instead, we 

recommended that DOD work to coordinate the efforts of individual MTFs 

to establish systems to collect and analyze performance data as part of 

the performance assessment process. In our review, we found that 

department chiefs were not always compiling and analyzing performance 

data that had already been collected when developing performance 

assessments. We also found that performance assessments often lacked 

supporting data. Four of the five MTFs we visited had undertaken “home 

grown” efforts to either develop, or invest in, software systems to help 

address the need to compile and analyze performance data to better 

inform performance assessments. Our recommendation is intended to 

help better ensure that performance data that MTFs are already collecting 

is both analyzed and completely documented in physician performance 

assessments, and also to reduce the potential for duplication of efforts 

and inefficient use of resources across multiple MTFs that are working 

individually to establish systems to meet similar needs.

DOD agreed to address our other recommendations to assure that 

information on clinical competence and practice history is documented 

and available to support privileging decisions—including clarifying 

requirements for how MTFs should document follow-up on peer 

recommendations; clarifying the information needed in CVs to identify 

unaccounted for periods in practice history; establishing requirements for 

the types of significant events that MTFs should document and report, 

including where that documentation should be filed; and establishing a 

process to ensure that all relevant information from the DPDB is 
 

Page 44 GAO-12-31 DOD Credentialing and Privileging

documented in the credentials file—as part of its revisions to DOD 

Regulation 6025.13-R and planned updates to CCQAS. However, DOD 

did not specify how the requirements would be revised or when it would 

complete the revisions. Without this information it is not possible for us to 

determine if the planned revisions will fully address the issues we 

identified in this report. For example, DOD noted that planned revisions to 

CCQAS will address current limitations on MTFs’ and the services’ ability 

to query the DPDB by making relevant information from the DPDB 

available in individual credentials files. However, without additional detail 

about the planned CCQAS revisions it is not possible for us to determine 

if the information that will be visible in the credentials file will fully ensure 

that all relevant information from the DPDB is documented in the 

credentials file.

In DOD’s response to our final recommendation—for DOD and the 

military services to implement an oversight process to conduct reviews of 

a sample of credentials files to identify and address areas of 

noncompliance and incomplete documentation—DOD acknowledged the 

need to measure compliance and noted that, until CCQAS revisions have 

been completed, more service-level reviews at the MTF level will be 

required. However, DOD did not provide sufficient detail about its planned 

oversight processes for us to determine if it will fully address the 

compliance and documentation issues we identified in this report. For 

example, DOD stated that compliance will be measured through 

accreditation visits and service reviews, but did not clarify how often these 

reviews will be conducted, how many credentials files will be reviewed, or 

the extent to which the reviews will be focused on credentialing and 

privileging issues, as opposed to accreditation standards more broadly. In 

addition, DOD noted that CCQAS will be the prime repository for all 

credentialing and privileging data moving forward. However, as we noted 

in our report, CCQAS does not provide the complete information 

necessary to determine whether MTFs are fully complying with 

credentialing and privileging requirements and completely documenting 

information needed to support credentialing and privileging decisions.

To fulfill their responsibilities to ensure that physicians who practice in 

DOD MTFs are qualified and clinically competent to care for 

servicemembers and their families, DOD and the military services must 

take the necessary steps to ensure that the weaknesses that we identified 

in their current physician credentialing and privileging processes are not 

allowed to persist. To date, DOD has not established time frames for the 

planned regulation updates, a redesign of CCQAS, clarifications and 

updates to existing requirements, and increased oversight that DOD 
 

Page 45 GAO-12-31 DOD Credentialing and Privileging

outlined in its comments. In addition, because DOD provided only limited 

detail on the specific actions it will take to address our recommendations, 

we cannot determine whether DOD has identified the steps needed to

ensure that it addresses the weaknesses in its credentialing and 

privileging processes. Addressing these weaknesses will be important to 

ensuring that servicemembers and their families receive care from 

physicians who are fully qualified.

We are sending copies of this report to the Secretary of Defense, 

appropriate congressional committees, and other interested parties. In 

addition, the report is available at no charge on the GAO Web site at 

http://www.gao.gov.

If you or your staffs have any questions about this report, please contact 

me at (202) 512-7114 or at williamsonr@gao.gov. Contact points for our 

Offices of Congressional Relations and Public Affairs may be found on 

the last page of this report. GAO staff who made major contributions to 

this report are listed in appendix III.

Randall B. Williamson

Director, Health Care
Appendix I: Scope and Methodology

Page 46 GAO-12-31 DOD Credentialing and Privileging

This appendix describes the information and methods we used to 

examine the extent to which: (1) the Department of Defense (DOD) 

ensures that the military services’ physician credentialing and privileging 

requirements are consistent across the Military Health System (MHS), 

(2) Army military treatment facilities (MTFs) are complying with the Army’s 

physician credentialing and privileging requirements, and (3) Army’s 

existing oversight and physician credentialing and privileging 

requirements are sufficient to assure compliance and complete 

documentation.

Specifically, we discuss our methods for reviewing DOD, Army, Navy, and 

Air Force requirements for physician credentialing and privileging; 

selecting Army MTFs for site visits; selecting a sample of medical 

specialties and credentials files to review; assessing selected MTFs’ 

compliance with Army requirements; and assessing the Army’s current 

oversight of the credentialing and privileging process. In addition to the 

methods described below, we also reviewed applicable standards 

published by The Joint Commission (a nonprofit organization that 

evaluates and accredits more than 16,000 health care organizations in 

the United States, including MTFs).1

To examine the extent to which DOD ensures the military services’ 

policies on physician credentialing and privileging are consistent across 

the MHS, we reviewed written policies issued by DOD, Army, Navy, and 

Air Force. We reviewed copies of the services’ written policies on 

credentialing and privileging—including DOD Instruction 6025.13 Medical 

Quality Assurance and Clinical Quality Management in the Military Health 

System (which replaced DOD Directive 6025.13 on February 17, 2011), 

DOD 6025.13-R Military Health System Clinical Quality Assurance 

Program Regulation, Army Regulation 40-68 Clinical Quality 

Management, Navy Bureau of Medicine and Surgery Instruction

 

1

DOD’s Quality Assurance regulations require that all MTFs shall meet or exceed the 

standards of appropriate external accrediting bodies, including accreditation of all 

hospitals by The Joint Commission. 

Appendix I: Scope and Methodology

Review of DOD, Army, 

Navy, and Air Force 

Written Policies on 

Physician Credentialing 

and Privileging
Appendix I: Scope and Methodology

Page 47 GAO-12-31 DOD Credentialing and Privileging

6320.66E, and Air Force Instruction 44-119 Medical Quality Operations.

2

We compared DOD and the military services’ requirements related to the 

primary source verification of a physician’s credentials, the process for 

evaluating a physician’s performance and determining their clinical 

competence, and the process for obtaining information related to a 

physician’s practice history.3

To obtain additional detail on inconsistencies we identified between DOD 

and the military services’ regulations, we interviewed officials from the 

offices responsible for developing physician credentialing and privileging 

requirements—including the Deputy Assistant Secretary of Defense for 

Clinical and Program Policy, the Chief of Quality Management for the 

U.S. Army Medical Command, the Deputy Department Head of Clinical 

Operations Quality and Risk Management for the Navy Bureau of 

Medicine and Surgery, and the Chief of Professional Staff Management 

for the Air Force Medical Operations Agency. We interviewed officials 

from DOD and the military services to obtain additional information on 

their processes for ensuring that physician credentialing and privileging 

requirements are consistent across the MHS, and to discuss potential 

challenges that the services and their MTFs face as the result of 

inconsistent requirements.

Specifically, we compared requirements 

regarding state medical licenses, peer recommendations, ongoing 

performance monitoring, malpractice and adverse action history, and 

practice experience. We selected these five credentialing and privileging 

requirements because they—unlike other requirements—address 

information about physicians that can change or be updated with new 

information periodically.

 

2

In order to be clear and consistent throughout this report, we refer to these policies as 

“requirements.” When we use the term “regulations,” we are referring to specific written 

policy documents labeled as such by the issuer. We limited the scope of our review to 

physician credentialing and privileging. Other types of medical providers, such as nurse 

practitioners and physician assistants, are also subject to specific credentialing and 

privileging requirements.

3

We limited our review to the primary source verification of state medical licenses because 

MTFs are required to primary source verify these credentials both at the time of privileging 

and at the time of license renewal. 
Appendix I: Scope and Methodology

Page 48 GAO-12-31 DOD Credentialing and Privileging

To determine the extent to which Army MTFs are complying with the 

Army’s requirements for credentialing and privileging of physicians, we 

selected a sample of five Army MTFs for our review. We limited our 

compliance review to Army MTFs in the United States because the Army 

has the largest staff of medical personnel, with active duty Army medical 

personnel accounting for more than 40 percent of DOD’s active duty 

medical workforce.4

To identify Army MTFs for our site visits, we examined relevant and 

available Army data. We selected our sample of site visit locations based 

on several factors, including the following:

During our site visits we reviewed a nongeneralizable 

sample of 150 credentials files (30 files at each MTF we selected) and 

interviewed MTF staff responsible for physician credentialing and 

privileging. Based on the sample of physician credentials files we 

reviewed at the five selected Army MTFs, we can discuss the selected 

MTF’s compliance for the credentials file we reviewed; we cannot 

generalize our findings to the remaining credentials files at the Army 

MTFs we selected, other Army MTFs, or MTFs managed by Navy or Air 

Force.

• The size of the MTF, based on data provided by Army Medical 

Command on the size of Army medical centers, community hospitals, 

and outpatient clinics, including estimated numbers of medical 

providers (including physicians) that held privileges at each Army MTF 

as of May 2010.

• The number of physicians holding privileges at each MTF within each 

of six selected medical specialties to allow us to select a sufficient 

number of credentials files for our sample (discussed below).

• Other considerations such as the feasibility and costs associated with 

travel to potential site visit locations.

 

4

We eliminated from consideration MTFs that operate overseas or in a combat area. We 

also limited our compliance review to Army facilities because at the time we initiated our 

review the Naval Audit Service was conducting a review of Navy’s credentialing and 

privileging processes and was using a similar file review methodology. 

Site and Sample Selection 

Methodology 

Site Visit Selection
Appendix I: Scope and Methodology

Page 49 GAO-12-31 DOD Credentialing and Privileging

Using these criteria, we selected the following five Army MTFs: DeWitt 

Army Community Hospital, Fort Belvoir, Virginia; Martin Army Community 

Hospital, Fort Benning, Georgia; Womack Army Medical Center, Fort 

Bragg, North Carolina; Ireland Army Community Hospital, Fort Knox, 

Kentucky; and Madigan Army Medical Center, Fort Lewis, Washington. 

We conducted our site visits from July 2010 through October 2010.

At each of the five Army MTFs we selected for our review we selected a 

nongeneralizable sample of 30 physician credentials files from the MTF’s 

physician population for a total of 150 credentials files across our sample. 

Our sample included credentials files for physicians serving in a variety of 

capacities, including active duty, reserve, or National Guard 

servicemembers;5

For each credentials file in our sample, we examined both paper and 

electronic documentation in the file to assess compliance with selected 

Army credentialing and privileging requirements. Specifically, we focused 

our review on assessing documentation in the credentials file that 

addressed the following requirements:

civilians; contractors; and volunteers. At each MTF we 

selected 5 physicians from each of the following six medical specialties; 

family practice, obstetrics and gynecology, surgery, pediatrics, radiology, 

and psychiatry. We selected these medical specialties to ensure that we 

had a sufficient number of physicians at each MTF to select 5 credential 

files from each specialty at each MTF. We used Army data on the number 

of physicians within each medical specialty at each MTF to select the six 

medical specialties that consistently had a sufficient number of privileged 

physicians for us to select at least 5 credentials files for each specialty. 

Additionally, we needed to ensure that each MTF had a sufficient number 

of physicians in each specialty that our sample could not be identified with 

specific individuals.

6

• Primary source verification of all physician state medical licenses ever 

held; 

 

5

Our sample included physicians from Army, Navy, and Air Force (we did not limit our 

sample to Army physicians). 

6

The results from our compliance review for some of the credentialing and privileging 

requirements do not total 150 because not all credentials files were required to comply 

with all of the requirements we examined for.

Medical Specialty and 

Credentials File Selection
Appendix I: Scope and Methodology

Page 50 GAO-12-31 DOD Credentialing and Privileging

• Peer recommendations, including documentation of any follow-up 

contacts that were made;

• Ongoing performance monitoring, including physician’s performance 

assessments, and documentation in the provider activity file (PAF);

• Malpractice and adverse action history, including queries of the 

National Practitioner Data Bank (NPDB) and the Defense Practitioner 

Data Bank (DPDB); and

• Physician’s practice history including information in the curriculum 

vitae (CV).7

Because our site selection process and our credentials file reviews 

included reviewing both paper files and electronic information contained 

in DOD’s Centralized Credentials Quality Assurance System (CCQAS), 

we assessed the reliability of this database. To do this, we examined 

relevant documentation and interviewed officials from the military 

services’ oversight agencies and DOD about measures taken to ensure 

reliability of information in CCQAS. We also reviewed the information in 

CCQAS for all 150 of the credentials files in our sample. Based on our 

review, we determined that the information in CCQAS was sufficiently 

reliable for the purposes of our report.

In addition to reviewing credentials files during our site visits, we reviewed 

meeting minutes from each MTF’s credentials committee for the 2 years 

prior to our site visit. For example, if we visited a site in July 2010, we 

requested meeting minutes from July 2008 through July 2010. We also 

reviewed any Army forms used during the credentialing and privileging 

process—such as peer recommendation forms and Army Form 5374

Performance Assessment—including forms which the MTF had modified 

to include standardized text.

Finally, we interviewed staff responsible for recommending or granting 

physician privileges—including department chiefs and the credentials

committee chairperson—and credentials staff responsible for maintaining 

a physician’s credentials file. We discussed with MTF staff at the end of 

each site visit all instances of documentation that we were unable to 

 

7

A curriculum vitae provides a short account of an individual’s career and qualifications, 

similar to a resume.
Appendix I: Scope and Methodology

Page 51 GAO-12-31 DOD Credentialing and Privileging

locate during our credentials file review in order to ensure that we had 

accurately captured the documentation present in the files we reviewed.

To determine the extent to which Army’s existing oversight and physician 

credentialing and privileging requirements are sufficient to assure 

compliance and complete documentation, we used information collected 

during our site visits to selected Army MTFs, reviewed applicable internal 

controls standards, and interviewed MTF staff and Army Medical

Command officials. Regarding internal controls, we considered Army’s 

oversight, including the provision of policy and guidance, against the 

standards described in the Standards for Internal Control in the Federal 

Government and the Internal Control Management and Evaluation Tool, 

particularly relevant internal control standards on information, monitoring, 

and communication.8

 

8

GAO, Standards for Internal Control in the Federal Government 

We interviewed Army officials to determine Army’s 

current processes for oversight of physician credentialing and privileging 

at Army MTFs. During our site visits, we also assessed the completeness 

of documentation to determine if relevant information was documented in 

credentials files. For example, for physicians in our sample, we compared 

documentation of relevant information from the DPDB in the credentials 

file to information we collected through our own searches of the DPDB to 

determine if all potentially relevant information was documented. In 

addition, we examined each credentials file to identify any significant 

events—such as an MTF’s consideration of potential concerns raised in 

performance assessments, NPDB queries, and other clinical competence 

and practice history documents—that may have occurred during an 

MTF’s review of the credentials file during the most recent privileging 

cycle. We searched for any documentation in the credentials files related 

to such events. We also interviewed MTF staff to discuss the examples of 

noncompliance with Army requirements and incomplete documentation 

that we identified in our review of credentials files. Lastly, to gain 

GAO/AIMD-00-21.3.1

(Washington, D.C.: November 1999). These standards provide the overall framework for

establishing guidelines for internal control. Internal control is synonymous with 

management control and comprises the plans, methods, and procedures used to meet 

missions, goals, and objectives. Internal control is not one event, but a series of actions 

and activities that occur throughout an entity’s operations and on an ongoing basis. The 

Internal Control Management and Evaluation Tool is based on the Standards for Internal 

Control in the Federal Government, and it is intended to provide a systematic approach to 

assessing an agency’s internal control structure. See GAO, Internal Control Management 

and Evaluation Tool, GAO-01-1008G (Washington, D.C.: August 2001).

Review of Sufficiency of 

Army Oversight and 

Requirements
Appendix I: Scope and Methodology

Page 52 GAO-12-31 DOD Credentialing and Privileging

additional insight into oversight of the credentialing and privileging 

process across the MHS, we interviewed officials from DOD, as well as 

Navy and Air Force oversight agencies.

We conducted this performance audit from May 2010 through December 

2011 in accordance with generally accepted government auditing 

standards. Those standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence to provide a reasonable basis for 

our findings and conclusions based on our audit objectives. We believe 

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives.
Appendix II: Comments from the Department 

of Defense

Page 53 GAO-12-31 DOD Credentialing and Privileging

Appendix II: Comments from the Department 

of Defense
Appendix II: Comments from the Department 

of Defense

Page 54 GAO-12-31 DOD Credentialing and Privileging
Appendix II: Comments from the Department 

of Defense

Page 55 GAO-12-31 DOD Credentialing and Privileging
Appendix II: Comments from the Department 

of Defense

Page 56 GAO-12-31 DOD Credentialing and Privileging
Appendix III: GAO Contact and Staff 

Acknowledgments

Page 57 GAO-12-31 DOD Credentialing and Privileging

Randall B. Williamson, (202) 512-7114 or williamsonr@gao.gov

In addition to the contact named above, Marcia A. Mann, Assistant 

Director; Chad Davenport; Cynthia Forbes; Janida Grima; Hannah 

Marston Minter; and Kaitlin M. McConnell made key contributions to this 

report. George Bogart provided legal support and Laurie L. Pachter 

assisted in message and report development.

Appendix III: GAO Contact and Staff 

Acknowledgments 

GAO Contact

Staff 

Acknowledgments 

(290848)
The Government Accountability Office, the audit, evaluation, and 

investigative arm of Congress, exists to support Congress in meeting its 

constitutional responsibilities and to help improve the performance and 

accountability of the federal government for the American people. GAO 

examines the use of public funds; evaluates federal programs and 

policies; and provides analyses, recommendations, and other assistance 

to help Congress make informed oversight, policy, and funding decisions. 

GAO’s commitment to good government is reflected in its core values of 

accountability, integrity, and reliability.

The fastest and easiest way to obtain copies of GAO documents at no 

cost is through GAO’s website (www.gao.gov). Each weekday afternoon, 

GAO posts on its website newly released reports, testimony, and 

correspondence. To have GAO e-mail you a list of newly posted products, 

go to www.gao.gov and select “E-mail Updates.”

The price of each GAO publication reflects GAO’s actual cost of 

production and distribution and depends on the number of pages in the 

publication and whether the publication is printed in color or black and 

white. Pricing and ordering information is posted on GAO’s website, 

http://www.gao.gov/ordering.htm. 

Place orders by calling (202) 512-6000, toll free (866) 801-7077, or 

TDD (202) 512-2537. 

Orders may be paid for using American Express, Discover Card, 

MasterCard, Visa, check, or money order. Call for additional information.

Connect with GAO on Facebook, Flickr, Twitter, and YouTube. 

Subscribe to our RSS Feeds or E-mail Updates. Listen to our Podcasts. 

Visit GAO on the web at www.gao.gov. 

Contact:

Website: www.gao.gov/fraudnet/fraudnet.htm

E-mail: fraudnet@gao.gov

Automated answering system: (800) 424-5454 or (202) 512-7470

Ralph Dawn, Managing Director, dawnr@gao.gov, (202) 512-4400

U.S. Government Accountability Office, 441 G Street NW, Room 7125

Washington, DC 20548

Chuck Young, Managing Director, youngc1@gao.gov, (202) 512-4800

U.S. Government Accountability Office, 441 G Street NW, Room 7149 

Washington, DC 20548

GAO’s Mission

Obtaining Copies of 

GAO Reports and 

Testimony 

Order by Phone

Connect with GAO

To Report Fraud, 

Waste, and Abuse in 

Federal Programs

Congressional 

Relations 

Public Affairs

Please Print on Recycled Paper.