SUBJECT: Physician Credentialing and Re-Appointment. INITIATOR: Manager, Medical Staff Credentialing (Signature on File) 03/2015 Jacqueline Ladewig

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1 Policy Number: SW010 Page 1 of 16 United Therapies, LLC provides management and other services to United Mobile Therapies, LLC (United Mobile) and United Urology Centers, LLC (United Urology). Each of United Mobile and United Urology operate under the name United Therapies (collectively, United Therapies) even though each is a separate and distinct legal entity with separate ownership. SUBJECT: Physician Credentialing and Re-Appointment INITIATOR: Manager, Medical Staff Credentialing (Signature on File) 03/2015 Jacqueline Ladewig Date APPROVAL: Director, Mobile Operations (Signature on File) 03/2015 Alan D. Maio Date APPROVAL: Vice-President Clinical Operations (Signature on File) 03/2015 Patricia Murphy Date APPROVAL: Chief Executive Officer (Signature on File) 03/2015 F. Bruce Cohen Date POLICY FIXED SITE PHYSICIANS United is committed to ensuring that all physicians who utilize our services are appropriately trained and credentialed. The decision by United s leaders to appoint and re-appoint physicians is based on the credentials information obtained. The Board of Directors has granted the exclusive authority to the Credentialing Committee to make all appointments and re-appointments to the Medical Staff. DEFINITIONS Clinical Leaders: United s Credentialing Committee is comprised of chosen clinical leaders to evaluate credentialing and privileging information presented by applicants. The Medical Director is United s highest clinical leader and the Chairman of the Credentialing Committee. ELIGIBILITY REQUIREMENTS 1. Current license by the state to practice medicine. 2. Board certified or board eligible* urologist or anesthesiologist within a period of time not longer than necessary to take two consecutive board certifying examinations. 3. Follow AMA Code of Ethics, or similar bodies. 4. Current coverage of professional liability insurance. 5. Current DEA/Controlled Substance Registration 6. Current medical malpractice in Illinois. 7. Completion of AUA approved ESWL training, Holmium training, TUNA, Green Light HPS and Cyber TM training, as applicable (urologists only). 8. Proof of current competence - 5 ESWL; and or 5 HPS procedures; and or 5 Cyber TM procedures in the prior twelve (12) months. 9. Active hospital/site staff privileges 10. Two (2) Peer References. 11. Verified copy of valid Government-issued photo identification issued by a state or federal agency (e.g., Driver's License or Passport). 12. Physician must not be excluded from participation in any federal or state healthcare program or be listed on the OIG Exclusion List or the GSA Excluded Parties List. *If Board Eligible, physician must submit letter from the Board.

2 Page 2 of 16 APPOINTMENT PROCEDURE A. APPLICATION 1. Requests for specific privileges must be in writing. When a physician calls to request privileges at United, a packet with the Physician Application and Request for Professional Staff Appointment form is sent (see Exhibit 1). In addition, the following documentation is requested. a. Copy of current state license; b. Copy of current DEA registration; c. Copy of Certificate Evidencing Malpractice Insurance Coverage; d. Copy of Board Certification or letter if Board Eligible; e. Copy of ESWL/TUNA/Green Light HPS/Cyber TM Training Certificate or Letter (urologists only); If Urology Residency training was completed after 1986, ESWL training was included in Residency and training certificate is not necessary. f. Copy of current Curriculum Vitae; g. Proof of completion of five (5) ESWL or five (5) HPS or five (5) Cyber TM procedures (urologists only) in the 12 months prior to submitting an application. i. If the physician has not treated the required number of patients, he/she may not be eligible to obtain privileges or receive credentialed status. h. Two (2) Peer References; and, (Peer Recommendations to include information as follows: Relevant training and experience; current competence; and any effects of health status on privileges being requested. Letters must be submitted by a peer of the same professional discipline as the applicant with personal knowledge of the applicant s ability to practice.) i. Signed Health Statement. j. Verified copy of valid Government-issued photo identification issued by a state or federal agency (e.g., Driver's License or Passport). 2. A Physician Application completed by the Physician must be received by United. The Physician Application includes the following information: a. Whether membership status or clinical privileges have ever been suspended, diminished or not renewed by any other institution. b. Whether the applicant s license has ever been revoked, suspended or jurisdiction to practice limited. c. Any adverse malpractice decision, settlement or pending litigation. d. Medical and/or mental or emotional condition which may impair ability to practice medicine. e. A signed release for authorization to obtain information regarding the physician from third parties. f. Whether the applicant has ever been excluded from participation in any federal or state healthcare program or whether exclusion is threatened. B. PRIMARY SOURCE VERIFICATION 1. After the Physician Application and required credentialing documentation is received, the AMA (American Medical Association) will be contacted to provide a physician profile to verify education, training and will include: a. Medical school; b. Year of graduation; c. Residency attendance and completion; d. Specialty; and, e. Board certification.

3 Page 3 of The Illinois Department of Professional Regulation is utilized to verify licensure status and any disciplinary actions taken against the applicant. A copy of the verification is printed and kept on file. 3. Upon re-appointment (every 2 years) and each license renewal (usually every 3 years) the Illinois Department of Professional Regulations, or applicable state agency for physicians licensed in other states, is contacted again to re-verify status. 4. Relevant training and experience (i.e., residency, HPS training certificates, etc.) will be verified with the primary source upon initial credentialing. C. APPOINTMENT STATUS AT OTHER HEALTHCARE ORGANIZATIONS 1. A letter is also sent to other healthcare organizations to confirm appointment status and to verify if any restriction(s) on privileges have been imposed. This information may also be obtained by phone; however, in most cases, will require a signed release from the physician. The signed release is included as part of the Physician Application. D. NATIONAL PRACTITIONER DATA BANK (NPDB) 1. The National Practitioner Data Bank is also queried on each physician at the time of initial appointment, reappointment, and for expansion of privileges. 2. Any and all adverse action reports will be reviewed by the Credentialing Committee prior to granting privileges. E. OFFICE OF INSPECTOR GENERAL OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES ( OIG ) EXCLUSION LIST AND SYSTEM FOR AWARD MANAGEMENT (FORMERLY GSA EXCLUDED PARTIES LIST) 1. The OIG Exclusion List and SAM System for Award Management are checked for each physician at the time the first case is scheduled. Physicians found on the exclusion list must be brought to the attention of Administration. 2 Each new physician will be checked by all names, maiden names, and aliases that are given on the application. 3. A copy of the printout from each web site check shall be kept in the appropriate file. 4. Each month, Credentialing will send a spreadsheet listing any newly credentialed physicians to the Compliance Officer no later than the 10 th of each month. 5. The Compliance Officer, in turn, will send this list to its contracted screening vendor for monthly exclusion screening. F. CREDENTIALS COMMITTEE REVIEW 1. After all required documentation is received and primary source verification is complete, the physician documentation is presented to the Credentialing Committee for final review and recommendation. 2. The Credentialing Committee will review all recommendations for appointment and reappointment and will grant final approval. a. Upon final approval, written notification and delineation of privileges will be sent to the physician. G. NOTIFICATION AND DELINEATION OF PRIVILEGES 1. The applicant is notified of the application status via letter; and if approved, is granted practice privileges. All individuals with clinical privileges must practice within the scope of their privileges. The notification letter delineates the procedures that may be performed by the physician. These procedures are listed below. a. Urologist: i. Lithotripsy (Unilateral/Bilateral)

4 Page 4 of 16 ii. Cystourethroscopy iii. Cysto Stone Manipulation with/without Extraction iv. Cysto Insert Stent (Unilateral/Bilateral) v. Cysto Insert Catheter (Unilateral/Bilateral) vi. Cysto with Stent Removal vii. Cysto with Retrograde viii. Retrograde ix. Nephrostogram x. KUB (Use and Interpretation of KUB) xi. Fluoroscopy xii. Holmium Laser xiii. Transurethral Need Ablation (TUNA) (only if MD has completed TUNA training) xiv. GreenLight HPS (PVP High Performance System) (only if MD has completed GreenLight HPS training) xv. Cyber TM xvi Ureteroscopy b. Anesthesiologist i. General Anesthetic ii. Spinal Anesthetic iii. Epidural Anesthetic iv. IV Sedation H. LEAVE OF ABSENCE (LOA) 1. When physicians ask for LOA, or, as soon as we find out a physician's status has changed, we will speak to the physician to confirm his/her status as Inactive. Once confirmed, the physician s status will be changed to Inactive. 2. Physicians will be allowed to take the LOA for 3 months, or, up to their next reappointment date, whichever comes first. a. The physician must contact us at least two weeks prior to the end of the 3 month period to let us know his/her current status. b. When physician contacts us we will complete the re-appointment procedure in full prior to changing the LOA status to active. c. If the physician does not notify us of new status at least two weeks prior to the end of the 3 month period, we will consider the physician s privileges voluntarily withdrawn. 3. If we cannot verify coverage of Malpractice insurance or Site privileges, we will Lapse that physician. a. When the physician submits current coverage, we will re-instate privileges. I. SUSPENSION OF ACTIVE PRIVILEGES 1. Pursuant to the Medical Staff By-Laws, the clinical privileges of a member of the Medical Staff shall be suspended immediately upon the occurrence of any of the following: a. the member is excluded from participation in any federal or state health care program; b. the member is listed on the General Services Administration s Excluded Parties List; c. the member is convicted of a felony or misdemeanor involving moral turpitude; d. the member s privileges at any hospital are suspended, limited or revoked;

5 Page 5 of 16 e. the member s license to practice medicine or license to dispense controlled substances is suspended, limited, or revoked; or f. the member materially violated United s Code of Business Conduct. 2. CHANGE OF PHYSICIAN PRACTICE OR ACTIVE STATUS ON ANY CREDENTIALING REQUIREMENTS a. It is the responsibility of each physician to notify United, in writing, if there is an event or incident that adversely affects any of the physician s eligibility requirements. Failure to so notify is grounds for dismissal. b. If there is an event or incident that is referred to the Credentialing Committee for review, the physician s privileges will be temporarily suspended until the Credentialing Committee is convened. c. As soon as we are notified of any change in a physician s practice (location) or change in any active status, such as site privileges, malpractice coverage, or moving within the same state, we must verify information. a. No physician will be permitted to provide care, treatment or services without current licensure, certification or registrations. Without such required credentials, the physician s privileges will be immediately lapsed. b. If malpractice coverage or site staff privileges are not current, we will lapse physician. c. If we cannot confirm with a physician that the information changed, because the physician did not give us a forwarding address, we will make the physician inactive. d. After a physician is Inactive, the physician must request a new application to complete the full credentialing process. e. When a physician is lapsed and then submits current coverage and/or credentials, United will reinstate physician after proper verification. 3. ABANDONMENT a. If adequate information has not been received from the applicant by the Credentialing Committee within twelve (12) months of receipt of the application form, the application shall be deemed abandoned by the applicant. CURRENT COMPETENCY ASSESSMENT A. Competency data will be reviewed on a semi-annual basis to ensure that all credentialed physicians maintain current competence to perform the privileged procedures. 1. In order to measure current competence, physicians are required to treat a minimum of five (5) ESWL; five (5) HPS procedures and or five (5) Cyber TM procedures in a rolling 12 month period to maintain competency for that privilege. 2. Physicians will receive a reminder notice no more than 60 days and no less than 30 days prior to their evaluation that they are required to perform the minimum number of cases. a. Physicians may submit documentation of cases performed at other facilities. Cases may be treated at any facility or with any provider and meet United s competence requirement. 3. If, after a rolling twelve (12) months, the physician has not provided information documenting cases performed at other facilities, United will deem the privileges as being withdrawn voluntarily. The result of the withdrawal is automatic termination of privileges. United will not consider the termination of privileges an adverse action. Therefore, the physician is not entitled to a fair hearing or appeal. United will not report the action to an external agency.

6 Page 6 of In order to apply for the re-instatement of privileges, physicians failing to meet United s competence standard must be able to demonstrate competence with the pre-requisite number of cases with a proctor: five (5) ESWL procedures and/or five (5) HPS procedures and/or five (5) Cyber TM procedures. a. For ESWL competence, the proctoring will be performed by another physician who has privileges for the procedure at issue. b. For HPS and/or Cyber TM competence, the proctoring will be performed by a certified HPS/Cyber TM technician. c. Cases may be proctored at United or another facility. d. Documentation of proctored cases should be submitted to United s Credentialing Committee for the privileges to be re-instated. B. Physicians must also maintain current malpractice insurance, current medical licensure, and a current DEA registration. These credentials will be checked quarterly by United to ensure that coverage and licensure is current. Physicians will be requested, in writing, to provide updated licensure and malpractice insurance prior to expiration. C. TEMPORARY PRIVILEGES 1. United does not grant temporary or disaster privileges to physicians. POLICY MOBILE SITE PHYSICIANS United Therapies Mobile ( UT Mobile ) is committed to ensuring that all physicians are appropriately trained and competent on the medical equipment UT Mobile provides to the Mobile sites. The Mobile Site is fully responsible for its credentialing policies, including, without limitation, its policies for determining that physician competency fully complies with the standards, requirements and obligations of the Joint Commission or other appropriate accrediting body. United Therapies will register the Mobile physicians in our credentialing system (CXM) with demographic and other pertinent information. DEFINITIONS United Therapies Mobile: Mobile Site: Fixed Site: Includes, United Urology Centers, LLC for Lithotripsy provided at Mobile Sites and United Mobile Therapies, LLC for laser services provided at Mobile Sites Hospitals, physician offices and/or Ambulatory Surgery Centers that contract with UT Mobile for service. United Therapies' fixed sites of service at Park Ridge, and LaGrange (ASC). APPLICATION An application requesting demographic information on each physician will be obtained by United in order to bill for services if it does so, and for any correspondence to be sent to the physician. When an application is not readily available, demographic information may be obtained from the hospital website or other correspondence from the physician s office. A. OFFICE OF INSPECTOR GENERAL OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES ( OIG ) EXCLUSION LIST AND SYSTEM FOR AWARD MANAGEMENT (FORMERLY GSA EXCLUDED PARTIES LIST)

7 Page 7 of The OIG Exclusion List and SAM System for Award Management are checked for each physician at the time the first case is scheduled. Physicians found on the exclusion list must be brought to the attention of Administration. 2 Each new physician will be checked by all names, maiden names, and aliases that are given on the application. 3. A copy of the printout from each web site check shall be kept in the appropriate file. 4. Each month, Credentialing will send a spreadsheet listing any newly credentialed physicians to the Compliance Officer no later than the 10 th of each month. 5. The Compliance Officer, in turn, will send this list to its contracted screening vendor for monthly exclusion screening. REAPPOINTMENT PROCEDURE United will send out correspondence to start the re-credentialing process. All physician appointments and reappointments are reviewed and revised at least every two years. A. REPRIVILEGING REQUIREMENTS 1. Demonstrate current competence 2. Peer Review 3. Verification of Current Licensure 4. Current DEA Registration 5. Malpractice Insurance coverage 6. Current Hospital/Site staff privileges 7. Verification of Board Certified /or Board Eligible 8. 2 Peer Reference letters B. PROCESS 1. Physicians are enrolled in the continuous query for NPDB, OIG Exclusion List, and SAM System for Award Management List. NBPD, OIG, and or Sam would notify us if an adverse report is found. 2. Collect forms listed below a. Physician Information Form b. Request for Professional Staff Reappointment c. Reappointment Questionnaire d. Health Status Statement 3. Primary source verification of re-privileging requirements must be completed. C. REPRIVILEGING REQUEST PROCESS 1. All physician appointments will be reviewed and renewed every two years. a. A letter informing the physicians of the need to renew their privileges will be sent approximately 90 to 120 days prior to the reappointment date. Proof of competence is required for re-appointment. b. If the physician has not completed the required paperwork prior to the reappointment date, the physician s privileges will be deemed to have lapsed as of the reappointment date. c. A final letter will be mailed to notify the physician if privileges are approved, denied or lapsed. d. If a physician is lapsed, for reasons other than current competence, and wishes to have his/her privileges reinstated, (s)he will need to submit proof of re-privileging requirements. Once United reviews and verifies accuracy, (s)he will be re-instated.

8 Page 8 of 16 D. PEER REVIEW/CURRENT COMPETENCE 1. Renewal of privileges will be based on Quality Improvement Data, as well as verification of current competency. a. In order to measure current competence, physicians are required to treat a minimum of five (5) ESWL, five (5) HPS, and/or five (5) Cyber TM procedures in a rolling 12 month period to maintain competency for that privilege. United will review the competency data on a semi-annual basis and at the time of reappointment. i. A physician may submit evidence of having performed cases at other facilities to meet the competency standards. b. If the physician does not provide information documenting cases performed at other facilities, United will deem the request for reappointment as being withdrawn voluntarily. The result of the withdrawal is automatic termination of the reapplication process. United will not consider the termination an adverse action. Therefore, the physician is not entitled to a fair hearing or appeal. United will not report the action to an external agency. c. In order to apply to have privileges reinstated, physicians failing to meet United s competence standard must be able to demonstrate competence with the prerequisite number of cases with a proctor: five (5) ESWL procedures and/or five (5) HPS procedures and/or five (5) Cyber TM procedures. i. For ESWL competence, the proctoring will be performed by another physician who has privileges for the procedure at issue. ii. For HPS/Cyber TM competence, the proctoring will be performed by a certified HPS/Cyber TM technician. iii. iv. Cases may be proctored at United or another facility. Documentation of proctored cases should be submitted to United s Credentialing Committee for the privileges to be re-instated. 2. A signed statement that he/she can perform the care, treatment and services that he/she has been providing is also required for re-appointment. E. VERIFICATION OF CURRENT LICENSURE 1. Once all required documentation is received, a letter is sent to other health care organizations to verify the physician s current appointment status and any restriction of privileges that may have been imposed. Licensure status is re-verified with the statelicensing agency, the National Practitioner Data Bank is queried for adverse privilege actions, and United s check of the OIG Exclusion List and GSA Excluded Parties List are verified. F. FINAL REVIEW AND APPROVAL 1. Once all required documentation is received, verified, and reviewed for accuracy and completeness, the re-appointment application is presented to the Credentialing Committee for final review and approval or denial. 2. The Credentialing Committee reviews all recommendations for re-appointment and will grant final approval. 3. Upon final approval, the physician will be notified via letter if approved and granted delineated privileges. 4. The physician will be notified via certified letter if privileges have been denied or lapsed. a. The physician will be able to appeal the Committee s decision by requesting an appeal hearing in writing within five working days from the date the physician was notified his/her admitting privileges were suspended/ denied/ lapsed.

9 Page 9 of 16 b. The appeal hearing will be consistent with procedures outlined in Corrective Action Physicians policy SW075 with regard to the HEARING COMMITTEE and FINAL APPEAL subsections. Cross-Reference SW075 Corrective Action Physicians SW080 Medical Staff Competence United Therapies' Medical Staff Bylaws Review/Revision History Reviewed Date(s): Revised Date(s): INITIATOR: Manager, Medical Staff Credentialing 7/1997; 6/1999; 8/1999; 9/1999; 7/1997; 6/1999; 8/1999; 9/1999; APPROVAL: Director, Mobile Operations 3/2000; 3/2001; 4/2001; 3/2002; 3/2000; 3/2001; 4/2001; 3/2002; 7/2002; 9/2002; 7/2003; 3/2004; 7/2002; 9/2002; 7/2003; 3/2004; Vice-President of Operations 6/2004; 7/2004; 2/2005; 4/2005; 7/2004; 2/2005; 4/2005; 7/2005; Chief Executive Officer 7/2005; 3/2006; 4/2006; 6/2006; 3/2006; 4/2006; 6/2006; 7/2006; 7/2006; 8/2006; 1/2007; 7/2007; 9/2007; 1/2008; 6/2008; 12/2008; 5/2009; 7/2009; 9/2009; 2/2010; 12/2010; 12/2011; 4/2012; 4/2013; 8/2006; 1/1007; 7/2007; 9/2007; 1/2008; 6/2008; 12/2008; 5/2009; 7/2009; 9/2009; 2/2010; 12/2010; 4/2014; 4/2015 4/2014; 4/2015

10 Page 10 of 16 Exhibit 1

11 Page 11 of 16 LICENSURE / CERTIFICATION INFORMATION: Drug Enforcement Agency (DEA) Certificate Number: Expiration Date: Copy attached. License Number: Expiration Date: Copy attached Controlled Substance Registration Number: Expiration Date: Copy attached Board Certification / Specialty Certificate Number and Issue Date Expiration Date: Board Eligible: Eligible Date: MALPRACTICE HISTORY: List below your current malpractice carrier and attach a copy of your Certificate Evidencing Malpractice Insurance Coverage. Current Carrier's Name: Policy Number: Dates of Coverage: Coverage Limits: EDUCATION and TRAINING: Medical Education Name of College / University - Location Year of Graduation: Internship Residency ESWL Training* Extracorporeal Shockwave Lithotripsy * ESWL Training: If your residency was completed prior to 1986, include a copy of your certificate or letter verifying ESWL training. PEER REFERENCES: Submit two (2) letters of Peer References, or list two (2) Peers who have direct knowledge of your clinical abilities. Include names, complete addresses, and telephone numbers. Physician Name Business Telephone Number ( ) Street Address City State Zip Code Physician Name Business Telephone Number ( ) Street Address City State Zip Code

12 Page 12 of 16 ATTESTATION: NOTE: If "YES" is checked, please explain fully on a separate sheet Health Status: Do you currently have any physical, mental, or emotional condition which may impair your ability to render the professional services which are the subject of this application? a. Do you have a history of medical treatment for chemical dependency or substance dependency? Insurance Coverage: Has your professional liability insurance coverage ever been denied, cancelled, non-renewed, or initially refused upon application? 3. License: Has your medical or professional license in any state ever been revoked, suspended, placed on probation, conditional status, or limited? a. Have you ever voluntarily surrendered your license? b. Are formal charges pending against you at this time? DEA: Has your DEA Registration Certificate ever been suspended, revoked, subjected to probation, placed on conditional status, or limited? Hospital Privileges: Do you currently have admitting privileges at any hospital or healthcare facility? a. Have you ever been refused membership on a hospital medical staff? b. Have you ever resigned or been asked to resign from a medical staff? c. Have your medical privileges at any healthcare facility ever been suspended, diminished, revoked or not renewed? 6. Criminal Offenses: Are you currently under indictment for any crimes? a. Have you ever been convicted of a criminal offense? Board Discipline: Have you ever been the subject of disciplinary proceedings by any professional association or organization (i.e., state licensing board, county, state or national professional society, hospital medical or clinical staff?) Malpractice Action: Have judgments or settlements been made against you in professional liability cases? a. Are any professional liability cases currently pending against you? b. Have you ever had professional liability insurance declined, cancelled, issued on special terms, or renewal refused? c. Has your request for any specific privileges ever been denied or granted with state limitations? I hereby submit this application for participation with United Therapies (United). I hereby certify that the information contained in this application is true, correct, and complete to the best of my knowledge. I attest that I have requested only those privileges that I am qualified to perform. I agree to be bound by the bylaws, rules and regulations, policies and procedures of United. I understand that this application will be reviewed based on the information I have provided, and I hereby grant immunity from any cause of action, suit or claim initiated by me against the participants reviewing and/or approving my application. I hereby agree that I will reimburse United and the peer review participants for their attorneys' fees in the event of an unsuccessful credentialing dispute. I hereby agree to notify United of any material change to the information reported on the application, including but not limited to, changes in status at other organizations, restrictions to any license, commencement of a formal investigation, or changes in physical or mental health within fifteen (15) days. Physician Signature M.D. Date

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