Credentialing dates back to as early as 1000 BC when the ancient Persian cult of Zoraster developed a process for 'licensure' of physicians.
An applicant needed to prove they successfully treated at least three heretics before gaining the right to practice medicine. If all three survived, they were deemed qualified to practice medicine 'forever and ever.'
Alternatively, if all three die, they may not practice medicine.
Today, the process of provider credentialing has changed significantly. Still, the goal remains the same - to assess the knowledge, skills, and experience of a provider before placing them into an environment where harm to others may result.
In this article, we will discuss provider credentialing and answer questions you may have regarding the process. We will also discuss what the future may hold for credentialing.
Provider credentialing is a multi-process approach for verifying, appraising, and certifying a provider's potential ability to provide safe, high-quality healthcare services within an organization.
It is a process of verification, appraisal, and certification used to verify a provider's competency and suitability for entry into a specific organized health environment. The procedure also involves checking for criminal records, sanctions, among other things.
Private and public payers, such as managed care and insurance companies, perform provider credentialing, sometimes independently and sometimes in conjunction with hospitals or healthcare systems, through credentialing verification organizations (CVOs).
The credentialing process of providers is done in phases by either the credentials department of the provider organization, the payer or a credentialing organization contracted by the provider organization.
As part of collecting a provider's information, obtaining all the certifications and documentation is necessary. Following this, the data is verified for accuracy and legitimacy.
In general, the specific data and documents collected are relatively uniform, although they may differ depending on which regulatory and accreditation body/bodies the organization subscribes to.
These agencies may include The Joint Commission (TJC), Centers for Medicare & Medicaid Services, The National Committee for Quality Assurance, individual state oversight bodies, the National Association for Healthcare Quality, DNV-GL, the Utilization Review Accreditation Commission, among others.
Finding the authentic source of data or documents is crucial in avoiding bias, inaccuracy, or unreliability in secondary sources of information.
Thanks to today's technology, healthcare providers or impostors can conveniently fabricate or exaggerate their qualifications to gain patient access.
Thus, PSV is a crucial stage in credentialing. Poor credentialing can lead to serious patient harm or death, in addition to millions of dollars in negligent credentialing lawsuits. A typical PSV procedure involves:
For practices seeking to become credentialed and favored by insurance companies, provider credentialing holds several advantages.
In the healthcare industry, the credentialing process provides quality assurance. It helps ensure healthcare standards are consistently met throughout the medical community and ensures patients receive the best possible care. Insurance companies tend to favor medical physicians and practices that are proven to be competent to perform their specialties to keep costs down.
Medical practices can also avoid losing thousands of dollars in revenue by avoiding delays or denials of reimbursements. Insurance payers may not reimburse medical facilities for their treatments if they fail to obtain proper credentialing. Medical practices that permit physicians to practice before or during credentialing processes may backdate reimbursements to cover the services provided.
Furthermore, credentialing ensures that clinicians and practices have the experience and skills necessary to perform medical procedures on patients. All the background knowledge credentialing provides helps restore trust between patients and healthcare providers, reducing the risk of medical errors. They can place their complete faith in their physicians with the knowledge they are qualified and merited to be their providers.
At least every three years, healthcare providers need to renew their credentials. Some healthcare facilities or insurance companies re-credential more frequently than others.
At least two reasons can delay provider credentialing:
It is not uncommon for newly graduated doctors to wait until they arrive in town before applying for credentials, even though they could have started the process weeks earlier. Referees may also delay the process by several weeks or even months, as their responses can take up to a year.
A credentialing application is not complete until an MCO has received all references - and credentialing cannot proceed until all referrals have arrived.
Several points must be validated, such as settlement records for professional liability, before credentials are approved, as per the NCQA "Primary Source Verification" standard. As a result, an MCO may withhold credentials from a newly hired physician until the last detail is verified.
Most health care organizations recommend applying 90 days before a practitioner's start date. The benchmark of 90 days allows extra time if verification sources fail to respond promptly or if discrepancies need to be clarified. In addition, all the approval committees will be able to access the provider's file.
Technology, health care integration, and increasing expectations of a high level of customer service (patients and providers) are transforming credentialing in the following ways:
This checklist is for you if you are starting up a new practice, and are attending to guarantee that each one of your providers has followed the credentialing process properly.
This checklist is for you if you are now running a medical practice and are just looking to add a new provider to your current team.
The goal of all health institutions is to maintain the best quality of care for their patients. Complications can arise when medical providers are not qualified to perform their duties. With credentialing, hospitals and other healthcare facilities can be confident that the medical providers they hire possess skills, expertise, records, and other credentials necessary to provide competent care.
Today, the credentialing process is more efficient. A significant number of healthcare institutions are moving away from paper-based processes and digitizing their credentialing. This ensures minor errors in gathering providers' information and fewer administrative expenses. In addition, cloud storage allows for easy access to view and edit records.
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Incident reporting improves safety for all healthcare participants. The main reason incident reporting exists is to ensure that everyone interacting with the healthcare facility (patients, staff, community, and facility) can live in a safe environment.