credentialing & privileging what executives should know may 12, 2015 karen beem, ms, rn...

Credentialing & Privileging

What Executives Should Know

May 12, 2015

Karen Beem, MS, RNStandards Interpretation

Objectives

Upon completion of this presentation, the participant will:

1.Discuss five (5) responsibilities of the Governing Body that are relevant to medical staff credentialing and privileging.

2.List ten (10) “Red Flags” that require investigation during review of applications for appointment to the medical staff.

3.List four (4) non-physician practitioners that may be granted privileges, consistent with State law, Medical Staff and Governing Body.

Credentialing & Privileging 2May 12, 2015

Objectives

4.Describe the new CMS guidelines regarding the flexibility of hospitals to allow non-members of the medical staff to write orders for outpatient services.


Definition

1. Credentialing: The process of verifying the qualifications of the professional to ensure current competence by assessing:

•Educational and training background •Work history •Current licensure •References, and •Ability to perform the services / privileges requested.


Definition

2. Privileges: • The specific patient care diagnostic or therapeutic procedures a

physician or non-physician practitioner is permitted to perform in a specific facility.

• Based on evaluation of the individual, the medical staff prepares recommendations to grant, deny, continue, revise, discontinue, limit, or revoke privileges, to the governing body.

• Only the Governing Body has the authority to grant:1) Clinical privileges, after reviewing medical staff

recommendations and / or2) Medical Staff membership


Definition

3. Primary Source Verification (PSV): • The verification of information directly from the original

source.

• Primary source verification is required to verify the accuracy of education, training, licensure, exams, and board certification information.


Definition

4. Non-Physician Practitioner: • Former terms: Midlevel Practitioner or Allied Health Practitioner

• Non-Physician Practitioner (NPP) includes, but not limited to:1. Nurse Practitioner2. Physician Assistant3. Clinical Nurse Specialist4. Certified Nurse Anesthesiologist5. Certified Nurse Midwife 6. Clinical Social Worker7. Clinical Psychologist8. Anesthesiologist Assistant


Definition

5. Appointment and Re-appointment: A. Initial Appointment:

• The first appointment to the medical staff. • Appointments may be no longer than 2 years, but may be less.

B. Re-appointment:• The medical staff must periodically re-appraise all professionals appointed to the

medical staff / granted medical staff privileges to determine current competence.

• Purpose of appraisal: To determine suitability of continuing the medical staff membership or privileges. Reappraisal is to be conducted at least every 24 months. Without renewal, practitioner is practicing without privileges (expired privileges).

• The medical staff appraisal procedures must evaluate each individual practitioner’s qualifications and demonstrated competencies to perform task / privileges.


Definition

6. “Complete” Application: A. Elements of a Complete Application:

1) The candidate has answered all questions on the application form(s)2) The candidate has provided all requested documents3) Three (3) or more letters of recommendation have been received4) Information has undergone Primary Source Verification 5) Fees have been paid

B. An incomplete application for membership / request for privileges cannot be submitted for consideration.

1) Temporary privileges may not be granted2) May not begin to see patients


Responsibilities of the Governing Body


The Governing Body1. Is legally responsible for the conduct of the hospital and the care

provided. (Standard 01.00.05)

2. Must determine which categories of practitioners are eligible candidates for appointment to the medical staff. (Standard 01.00.08)

3. Must appoint members of the medical staff after considering the recommendations of the medical staff. (Standard 01.00.09)

4. Must approve the medical staff bylaws and other medical staff rules and regulations (including changes). (Standard 01.00.11)


The Governing Body

5. Has the authority to make final decisions regarding appointment and granting of privileges. (Standard 01.00.09)

6. Consistent with medical staff criteria, State and Federal regulations, determines whether to:

• Grant, Deny, Continue, Revise, Discontinue, Limit or Revoke privileges including medical staff membership


Why Is It Important for Executives to Understand the Credentialing & Privileging Process?


Negligent Credentialing

Plaintiff Must Prove:1.Hospital failed to exercise reasonable care in granting medical staff privileges or membership to a physician;

2.The physician that was negligently credentialed breached the standard of care when treating the plaintiff; and

3.The negligent credentialing of the negligent physician was a proximate cause of the plaintiff's injuries


Cases of Negligent Credentialing

1. Johnson v. Misericordia• False information & omitted information on the application• Hospital did not verify the information

2. Frigo v. Silver Cross Hospital (2007) ($7,775,688)• Physician did not initially meet eligibility requirements

• Reappointed without meeting eligibility requirements

• Kadlec v. Lakeview Anesthesia Assoc. and Lakeview Medical Center• Peer references provided misleading information


Minimize Risk

Regular Training:1. Medical Staff Office personnel2. Medical Staff Department Chairs3. Medical Staff Officers4. Members

• Medical Executive Committee• Credentials Committee

5. Members, Governing Body


Minimize Risk

Policies:1. Bylaws, Rules & Regs, and medical staff policies

2. Understand Bylaws and policies

3. Consistent application of Bylaws and policies

4. Update Bylaws and policies


Audit Bylaws to Determine Gaps

Ensure Bylaws are current and consistent with State, Federal, and accreditation requirements

Are the Medical Staff Bylaws consistent with Governing Body Bylaws?

Are members of the medical staff required to comply with “Code of Conduct / Disruptive Behavior” policy?


Do the Bylaws Address?

1. Requirement to Report to the Medical Staff:A. Within 5 days -

– Insurance coverage reduced below required limits– Felony convictions– Medicare/Medicaid sanctions– Loss of privileges– Loss of license

B. Malpractice suits within established timelines



2. On-call Requirements:A. Expected response time

B. Responsibility to identify the back-up physician1) Person with same privileges2) Person agreed to serve as back-up for the dates specified

C. Physician responsibility to provide post-ED follow-up treatment



3. Medical Record Documentation Expectations:A. History & Physical within 30 days

B. Written Updated Examination to the History & Physical:• Within 24 hours of admission • Prior to anesthesia

C. Discharge Summary

D. Authentication of verbal orders



4. Requirements to Query the NPDB:A. When Medical Staff will Query:

1) Initial Appointment2) Request for NEW Privileges3) Re-appointment

B. Whom the Medical Staff will Query:1) Physicians and Dentists2) Non-physician practitioners3) Locum Tenens4) Requests for Temporary Privileges



C. What the Medical Staff will Report to NPDB

• Denials or restrictions of clinical privileges for more than 30 days that result from professional review actions relating to the practitioner’s professional competence or professional conduct that adversely affects, or could adversely affect, the health or welfare of a patient


Responsibility of the Governing Body: Competent Practitioners


Eligibility for Appointment

All practitioners who require privileges in order to furnish care to hospital patients:1.Must be evaluated under the hospital’s medical staff privileging system

2.Before the governing body may grant privileges.

3.Includes physicians and non-physician practitioners granted privileges.

(see 03.00.01)


Duty of the Organization

The hospital is responsible to grant privileges only to competent practitioners.


Application Process


Pre-Application

Purpose: 1.To screen applicants for basic eligibility.

2.Denial of a Pre-Application is NOT reportable to NPDB.


Pre-Application Packet

Medical Staff with Legal Counsel Determine Materials:1.Eligibility Requirements to Receive Full Application

a) Distance Requirements: Home and Officeb) Current license in the State where the patient will be treated

2.Applicant to sign an “Absolute Release and Waiver of Liability” Form

3.Affiliation with Competitor:1. Are you now or have you been employed by a competitor or have financial

interest in a competitor?2. Are you now or have you been a member of the medical staff leadership at a

competing hospital, ASC, or entity?


Decision to Send Full Application

A. Decision to send Full Application • Consistent application per policy

B. Application Materials:1. State Mandated Application form

2. Hospital-specific Application form

3. Request for Privileges

4. Medical Staff Bylaws, Governing Body Bylaws and Rules & Regulations, relevant Medical Staff Policies, etc.


Application Packet

5. Request List of Professional References

6. Applicant to sign affidavit:• “Information provided is current and accurate.” • This cannot be delegated


Begin Processing Application

1. Upon receipt of the signed Absolute Waiver:a) Hospital sends requests for references:

1) Attach copy of the signed Absolute Waiver2) Attach copy of government-issued photo; verify individual

b) Acceptable to send electronic request for references• Reduces delays with response• Auto-resend

2. Medical Staff Office begins data collection and verification a) Individual Credentials Fileb) Application Checklist


Evaluation of Application

Key elements to identify during review process

Red Flags

•Red flags do not automatically preclude a practitioner from the medical staff.

•These trigger the need for investigation of the circumstances.


Red Flags

The Applicant:1.Submits an incomplete application

2.Changed medical schools or residency programs or gaps in training

3.Unexplained / unaccounted time gaps in education / employment.

4.Practiced or licensed in 3 or more states

5.Changed practice locations more than 3 times in 10 years


Red Flags

6. Inability to maintain a medical practice in the facility’s service area.

7. Resignation from a medical staff at any time in career.

8. Reports of problems in an applicant’s professional practice.

9. One or more references that raise concerns or questions, e.g., “Please call for information.”

10. No response to a reference inquiry from an applicant’s past affiliation.


Red Flags11. Disciplinary actions by medical staff organizations, hospitals, state

medical boards, or professional societies.

12. Any past or pending state licensing board, medical staff organization, or professional society investigative proceedings.

13. Any claims or investigations of fraud, abuse and/or misconduct from professional review organizations, third-party payers, or government entities.

14. Little or no verified coverage from a professional liability insurance policy.


Red Flags

15. Jury verdicts and settlements for professional liability claims.

16. Any discrepancies identified between:• Application• Primary Source Verification information• References


Application Verification: Licensure

A. Licensure History:a) Initial Appointment: Primary Source Verification

A.Licensure, registration, and certification historyB.Must be licensed in state where patients are locatedC. Check all licenses (current and previous) and any previous

healthcare disciplines, e.g., NP, PAD.Lifetime history preferredE. Check for sanctions

b) Reappointment• Any licenses surrendered since last appointment?


Application Verification: Licensure

c) Primary Source Verification1) State Licensing Boards, FSMB

• Any sanctions?

2) DEA Registration:• DEA controlled-substance registration actions

3) Query the NPDB c) Medical malpractice payments d) OIG Exclusions from Medicare and Medicaid e) Adverse licensure actions related to professional competence

or conduct


Application Verification: Education

B. Medical Education & Post-Graduate Training:a) Initial Appointment:

• Request lifetime clinical education and training history: medical, osteopathic, podiatric, dental, residency and fellowship programs

• Require for each program: 1) Start Date and End Date2) Explain any gaps > 90 days


Application Verification: Education

b) Re-appointment: N/A

c) Request for New Privileges: •Request education and training

d) Primary Source Verification: •National Student Clearinghouse, AMA, AOA, ECFMG, and applicable professional schools or residency training programs.


Application Verification: Insurance

C. Medical Malpractice Insurance History:a) Initial Appointment

• Open & pending cases, claims, lawsuits, settlements, judgements, and dismissed cases

• Minimum: 5 year malpractice history• Best Practice: 10 year history of claims• Appropriate coverage for the requested privilege?

b) Reappointment• Pending cases, claims, lawsuits, settlements, judgements

for past 2 years



c) Request1) Former Malpractice Insurance policies (past 5 years)

– Policy number

2) Current Certificates of Insurance: Determine– Policy number– Limits and exclusions– Per occurrence?

3) Current Coverage Schedule: Determine– Apply to multiple hospitals if claims are made?– Apply to multiple members of a group? – Coverage if depleted by others in the group?



d) Legal Counsel to Advise• Interpretation of the Coverage Schedule• Benefits of requiring a tail for prior acts coverage

e) Verify Insurance Company Rating• Consistent with Governing Body Listing, e.g., Standard and Poor’s

or AM Best• Legal Counsel to advise regarding low rated companies

f) Primary Source Verification• Current and Past Malpractice Carriers• NPDB


Application Verification: Boards

D. Specialty Board Certification Status:a) Initial Appointment

• Board Status: None or current certification • Eligible to take exam? When?• Components taken? Passed? Failed?• Number of times exam was taken?

b) Reappointment• Consistent application of policies• Monitor completion of exams• Compliance with Maintenance of Certification (MOC)


Application Verification: Sanctions

E. Sanctions or Disciplinary Actions:a) Initial Appointment & Reappointment

1) Disciplinary actions taken or investigations pending by hospitals or other healthcare facilities, specialty boards, Medicare / Medicaid;

2) Actions against the Federal Drug Enforcement Agency (DEA) certificate or State Controlled Dangerous Substances (CDS) certificate; and

3) Actions listed in the National Practitioner Data Bank (NPDB).


Application Verification: Sanctions

b) Primary Source Verification:• NPDB, FSMB, and OIG List of Excluded Individuals/Entities

(LEIE) monthly

c) Hospital Responsibility: 1) To investigate all sanctions or disciplinary actions2) Consistent application of Bylaws / policies3) Document findings, discussions, and actions taken to resolve


Application Verification: Criminal

F. Criminal History:a) Initial Appointment

• Minimum: 7 – 10 years; Lifetime history preferred• Investigate: Information provided in the application or as required

by federal and state regulations.

b) Reappointment• As required by federal and state regulations.


Application Verification: Criminal

c) Primary Source Verification:1) Federal, State, and County Databases

– Each county in which applicant resided and worked

2) Finger printing: Optional– State vs. Nationwide– Fee for service

d) Investigate findings


Application Verification: Employment

G. Healthcare Employment History:1. Initial Appointment & Reappointment

A. Healthcare Employment:To provide a chronological, comprehensive listing of each facility where clinical privileges were held

1) Start Date and End Date2) Explain gaps

B. Primary Source Verification:1)Dates2)Verify: Left in good standing


Application Verification: Employment

C.Investigate: 1) Gaps in employment

2) Did not leave in “good standing”

3) Terminations, challenges, pending investigations and decisions, voluntary resignations, and relinquishments of membership or privileges

2) Termination or non-renewal of employment contracts


Application Verification: References

H. Professional References:a) Initial Appointment

1) Purpose: Determine current competence, ability to perform requested privileges, and peer recommendations

2) Attach:• Copy of a government-issued photo when sending requests for

reference; ask for verification of individual• Current list of privileges

b) Reappointment• Letters of reference are not required• OPPE and peer review will suffice


Application Verification: References

c) Professional References 1) Professional authorities who have worked with applicant in past 2

years2) Can authoritatively speak to experience and competence3) Able to address current competencies (provide tool and list of

privileges)

d) Selection of Peer References 1) Within the same discipline; preferably, not a partner2) At least one (1) physician for NP and PA


Application Verification: Activity

I. Clinical Activity:a) Initial Appointment

1) Request 6 – 24 month summary (numbers and type of procedures / conditions)

2) Activity logs to Support Requested Privileges:a) Submit from Residency / Fellowship programsb) Former / other affiliates

3) Current Competence a) OPPE report from former / other affiliates


Application Verification: Activity

I. Clinical Activity – Submit Procedure Logs:

b) Reappointment – Activity for past 2 years1) Obtain current facility procedure report

2) Low / no volume: Request reports from external source, consistent with policy


Credentialing and Privileging Process

A. Review of Applications:1. Consistent application of policy

2. Incomplete applications may not be forwarded for review

3. Medical Staff policy defines time limits for application completion

B. Summary of Red Flags Document findings, discussions, and actions.


Credentialing and Privileging Process

The Completed Application is submitted to:1.Chair, respective Medical Department

2.Credentials Committee: Prepares recommendations for privileges

3.Medical Executive Committee: Prepares recommendations for privileges

4.Governing Body: Reviews Medical Staff recommendations; grants / denies / revises privileges

5.Applicant is notified of the Governing Body’s decision

6.Begin: FPPE and OPPE


The Governing Body Meeting Minutes to Reflect

1)“At the recommendation of the Medical Staff…”

2)“The Governing Body grants to (NAME) the following privileges ….”

3)Effective date of the privileges and expiration date, e.g., a) Effective at Midnight, May 1, 2015 b) Expires at 11:59 pm, April 30, 2017


Multi-hospital Health Systems

Privileges may only be granted for procedures offered at the hospital:

1)Memorial Medical Center: • Offers a comprehensive neurosurgery service

2)Community Hospital: • No neurosurgery• Cannot grant neurosurgical privileges

3)The Governing Body meeting minutes must reflect the privileges granted to each practitioner for each hospital



Is credentialing and privileging required for physicians and non-physician practitioners working in an ambulatory settings?

Answer:•Yes, if the ambulatory setting bills for services using the hospital CCN (Medicare Provider Number).

•This is considered to be a department of the hospital.



Is credentialing and privileging required for physicians and non-physician practitioners who are employees of the hospital?

Answer:•Yes, all practitioners who require privileges in order to furnish care to hospital patients must be evaluated under the hospital’s medical staff privileging system before the hospital’s governing body may grant them privileges.

(Standard 03.00.01)



Is credentialing and privileging required for telemedicine practitioners?

Answer:1.Full details: See standards 01.00.15; 01.00.16; 03.00.08; and 03.00.09

2.The credentialing may be performed onsite or at distant hospital / entity.

3.Be sure the medical staff makes recommendations to the governing body.

4.Ensure the governing body grants the privileges.



Temporary Privileges1.Must be infrequently granted

2.A “Completed application” is required

3.Review with recommendations for privileges by:a) Chief of Staff / Department Chairb) CEO

4.Process:Is the Governing Body meeting scheduled too proximal to the expiration of

privileges to avoid:

• Holidays & inclement weather



Locum Tenens1.Consistent application of Bylaws and policies

2.A “Completed application” is required 3.Review with recommendations by:

a) Chief of Staff / Department Chairb) CEO

4.Process:• Has the Medical Staff and the Governing Body established procedures to

reduce “last minute” requests?


Governing Body Responsibility:Determine Categories Eligible for Appointment


Categories Eligible for Appointment

The governing body must determine, in accordance with State law, which categories of practitioners are eligible candidates for appointment to the medical staff. (Standard 01.00.08)

Non-physician Practitioners:The governing body has the authority, in accordance with State law,•To grant medical staff privileges and membership to non- physician practitioners.

•Granting medical staff privileges and membership to non-physician practitioners is an option available to the governing body; it is not a requirement.


CMS Update:Privileges to Write Orders for Services

1. Services must be ordered by a qualified and licensed practitioner who is responsible for the care of the patient.

2. Must have medical staff privileges to write orders for these services.

1. Such privileges must be granted consistent with the State’s scope of practice law, hospital policies and procedures, developed by the medical staff and approved by the governing body and may include:1. Nurse Practitioners2. Physicians’ Assistants3. Clinical Nurse Specialists 4. Others consistent with State scope of practice, medical staff, and

governing body policies


CMS Update: Orders for ServicesHospitals have flexibility to grant privileges to write orders:

1. Respiratory Care Services• Standard 17.00.07 Services Provided §482.57(b)(3)

2. Rehabilitation Services• Standard 26.00.06 Services Provided §482.56(b)

3. Diet Orders: Therapeutic Diets & Supplements• Standard 24.00.07 Diet Orders §482.28(b)(2)


Non-Physician Practitioners

Eligible for Privileges1. Nurse Practitioner2. Physician Assistant3. Clinical Nurse Specialist4. Certified Nurse

Anesthesiologist5. Certified Nurse Midwife 6. Clinical Social Worker7. Clinical Psychologist8. Anesthesiologist Assistant

New: Option to Privilege1. Physical Therapists2. Occupational Therapists3. Speech Language

Therapists4. Qualified Dietitians /

Nutritionists 5. Certain Licensed

Pharmacists


State Law & Scope of PracticePrivileges to Write Orders:

1.Governing body, when permitted by State law and upon recommendation of the medical staff, may grant privileges

2.Hospital is responsible to ensure the individual is qualified under State law before appointing to the medical staff or granting privileges.


Periodic Appraisal of MembersThe Medical Staff must periodically appraise its members.

• At regular intervals, the medical staff must appraise the qualifications of all practitioners including non-physician practitioners.

• To determine competency and suitability for continuing privileges

• The OPPE / FPPE process for all practitioners with privileges

• At least every 24 months(See 03.00.02)


Practitioners Granted Privileges Only

The governing body and medical staff must exercise oversight:

•Through credentialing

•Competency review (OPPE / FPPE) of those practitioners to whom it grants privileges,

•Just as it would for those practitioners appointed to its medical staff.

(Standard 03.00.01)


CMS Update: Outpatient Services


31.00.11 Orders for Outpatient Services

Services must be ordered by a practitioner who:1.Is responsible for the care of the patient.

2.Is licensed in the State where he or she provides care to the patient.

3.Is acting within his or her scope of practice under State law.

4.Is authorized in accordance with State law and policies adopted by the medical staff, and approved by the governing body, to order the applicable outpatient services.


Orders for Outpatient Services

Hospital Policy:

For practitioners who do not hold hospital privileges the hospital’s medical staff policy may permit them

to refer patients to the hospital with orders for specific outpatient services

If all of the above 4 criteria are met.



Policy Must Address:1. How the hospital verifies the referring/ordering practitioner is appropriately licensed and acting

within his/her scope of practice.

2.The regulation does not prescribe the details of the licensure and scope of practice verification process but instead provides a hospital the flexibility to accomplish this in the manner it finds efficient and effective. 3.The hospital is expected to ensure the verification process is followed for all outpatient services in all hospital locations.



Policy Must Also:1.Make clear whether the policy applies to all hospital outpatient services, or

2.Whether there are specific services for which orders may only be accepted from practitioners with medical staff privileges.

Example: •A hospital prefers to not accept orders for a regimen of outpatient chemotherapy or outpatient therapeutic nuclear medicine services from a physician without privileges.

•Policy must make these exceptions clear to the general authorization for accepting orders from referring practitioners.


National Practitioner Data Bank


NPDB GuidelinesApril 6, 2015

National Practitioner Data Bank U.S. Department of Health and Human Services

Clearinghouse:1.To improve the quality of medical care.

2.To restrict incompetent physicians and dentists from moving from State to State without disclosure or discovery of previous damaging or incompetent performance.

3.2013: Consolidated NPDB and HIPDB to eliminate duplication.


Must Report to NPDB

Adverse Clinical Privilege Actions •Any professional review action that adversely affects the clinical privileges of a physician or dentist for a period of more than 30 days, or •The acceptance of the surrender of clinical privileges, or any restriction of such privileges by a physician or dentist,

– While the physician or dentist is under investigation by a health care entity relating to possible incompetence or improper professional conduct, or

– In return for not conducting such an investigation or proceeding.


Must Report to NPDB

2. Denials or Restrictions: • Based on Professional Review Actions relating to professional competence or

conduct that adversely affects, or could adversely affect, the health or welfare of a patient

3. Voluntary Withdrawal: • If a practitioner applies for renewal of a medical staff appointment or clinical

privileges and voluntarily withdraws that application while under investigation or possible professional incompetence or improper professional conduct or in return for not conducting such an investigation or not taking a professional review action

3.Non-renewals:• While under investigation by the health care entity for possible professional

incompetence or improper professional conduct


Must Report to NPDB

4. Summary Suspensions:• If imposed for more than 30 days• Based on professional competence or professional conduct• Result of professional review action

5. Proctors:• If, as a result of professional review action r/t professional competence or

conduct, a proctor is assigned for a period >30 days…

• If, for a period lasting more than 30 days, the physician or dentist cannot perform certain procedures without proctor approval or without the proctor being present and watching the physician or dentist, the action constitutes a restriction of clinical privileges and must be reported to the NPDB.


Do NOT Report to NPDB

1. Denials or Restrictions:• Clinical privileges at appointment or reappointment that occurs

soley because a practitioner does not meet a health care institution's established threshold criteria for that particular privilege (as these are not the result of a professional review action relating to professional competence or conduct.)

• If a hospital or other health care entity retroactively changes the threshold criteria for a particular clinical privilege, a physician who does not meet the new criteria will lose previously granted clinical privileges.


Generally, Do NOT Report to NPDB

1. Voluntary withdrawal of an initial application for medical staff appointment or clinical privileges prior to a final professional review action generally should not be reported to the NPDB.

2. Non-renewals of medical staff appointment or clinical privileges.


NPDB Requirements

3. Provides Additional Information & Examples:• Defines “Investigation”• 30-day requirements• Timeline for reporting• Specific adverse events to be reported• Professional to be reported• Generating Reports

1) Initial Reports2) Corrected Reports


References• CMS Final Rule: Burden Reduction May 12, 2014

• CMS Survey & Certification Memo 14-45 (12-15-2014)

• CMS Survey & Certification Memo 15-22 (1-30-15)

• CMS Acute Care Hospital Interpretative Guidelines – Appendix A (4-1-2015)

• National Practitioner Data Bank (4-6-2015) Link = http://www.npdb.hrsa.gov/resources/NPDBGuidebook.pdf#page=78


http://www.npdb.hrsa.gov/resources/NPDBGuidebook.pdf#page=78

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QUESTIONS?

Karen Beem 312-202-8069

Donna Tiberi 312-202-8073

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