7 Things to Know about Medical Credentialing

Credentialing is about conducting background checks to confirm the qualifications and skills of medical professionals to maintain certain standards among a variety of healthcare providers including – Dentists, Physicians, Counselors, Psychologists, Physician Assistants, Optometrists, and Ophthalmologists, etc. Moreover, Credentialing is crucial for new hires, it’s conducted at regular intervals to adapt to the quality standards of regulatory and accrediting firms like the National Committee for Quality Assurance (NCQA), The Joint Commission (TJC), and the Centers for Medicare and Medicaid Services (CMS).

Credentialing basically consists of two parts, credentialing & privileging. Whereas, Credentialing is the process of verifying competency to grant privileges, Privileging is the process of authorizing providers to perform specific procedures based on their competency. General competency is measured based on six areas, which are:

1. Professionalism
2. Patient care
3. Medical clinical knowledge
4. Interpersonal and communication skills
5. Practice-based learning and improvement
6. System-based practice

Let’s take a look at the things you should know about Medical Credentialing beginning from its concept.

Concept of Medical Credentialing

Credentialing has changed a lot in modern times. However, the core concept remains the same which is to ensure that the doctors who are practicing medicine in a state or city are qualified to safely do so without endangering others.

Modern credentialing reviews different pieces of information including:

• Education and Training
• Qualifications
• Career history
• Licensing
• Residency
• Specialty certificates

Advantages

The most important advantage of medical credentialing is that it promotes confidence in the quality of medical professionals, minimizes errors, and keeps operating costs down. The system makes sure that everyone is taken care of. Healthcare facilities can rest assured that the staff they hire are well trained to provide care at the highest possible standards. Insurance companies operate on the incentive to keep their costs down and hence only hire those professionals who are competent enough to efficiently practice medicine.

Patients get the greatest gift of all, the confidence that the medical facility is conducting rigorous practices to ensure that the care and treatment they receive are of the highest medical standards.

Process

The process of credentialing can vary depending on the facility where you apply, and the specialty in which you work. The basic process, however, is similar across all situations.

An important thing to note is that the process of credentialing can take anywhere from 90 to 150 days depending on the market so you must give yourself plenty of time to complete the process.

The facility you work at, may have a credentialing service they regularly use, or you can contact the credentialing authority, called a Credentials Verification Organization or CVO to request an application. You may submit it, after receiving and completing the application review and the application checklist. Make sure you fill the application paperwork correctly or it will slow down the credentialing process.

The CVO staff will begin the process of verifying your credentials after which the file is passed on to the credentialing committee who will make the ultimate decision.

Primary Source Verification

Primary source verification refers to confirming the authenticity of the self-reported information with the primary source. To prevent fraud, no documents from the applicant or a third party are accepted. The team at the CVO will reach out to The Board of Medicine directly to confirm their medical license.

They also reach out to previous places of employment including hospitals where the providers hold privileges to ensure that they are in good standing. They may also contact your place of education and further training to ensure there is no discrepancy in the information/documents you have provided.

Documentation

You will be asked to provide a list of documents to provide proof of your professional identity. To ensure a quick and smooth experience, you should be prepared to provide the following documents:

• Proof of training, including residency and fellowship
• Medical school diploma
• Board certifications
• DEA certification
• Life support certifications, such as advanced cardiac life support (ACLS)
• Medical licenses
• Official change-of-name documentation, if applicable

You can scan, email, fax, or mail these documents to the credentialing team. Hard copies aren’t usually needed but you should be prepared to provide them to streamline the credentialing procedure.

Internal vs External Credentialing

When the internal credentialing team verifies your data, your agency credentialing is complete and remains valid for up to two years. However, you will also have to go through a separate credentialing process for every contract or assignment at each new hospital. This is called external credentialing which is done because every facility has its prerequisites and conducts its primary source verifications.

The good news is that the external credentialing team fills the hospital application with the information, the internal credentialing team has gathered. It saves a lot of time not just for you, but for the credentialing team as well.

After the team fills out as much information as they can, they send it to you to finish and forward it to the hospital. The team’s ultimate goal is to save time for the doctors so that they can treat patients instead of filling out paperwork.

Tips for Credentialing Process

Clear communication – Timely communication with credentialing representatives will help prevent delays. Let them know whether you prefer email, phone calls, or even text messages so they can contact you when needed.

Full disclosure – You should report all licensure sanctions or malpractice claims truthfully and in detail because the credentialing teams have to investigate any discrepancies. The process becomes much easier when you provide accurate information.

Start early – It’s not entirely uncommon for the credentialing process to take more than three to four months. It’s always better to start the process at least four months before you expect to start working at your practice.

Outsource Credentialing – Choosing to outsource the credentialing services is a good idea as professional credentialing service providers navigate the process every day and save a lot of time for you by getting the required things right the first time.

Attestations – It’s the paperwork that ensures that your application is valid and has accurate details. In case you change any information after the application is completed, you would be required to rewrite and resubmit the papers. To make your credentialing process a bit easier and simpler, you can stay with a relevant organization like Coalition for Affordable Quality Healthcare (CAQH).

General FAQs regarding Medical Credentialing

Q. Can a medical professional work during the credentialing process?

Ans. No. Any healthcare professional is required to wait until the process is complete and approved by the credentialing team/authority before s/he can start working.

Q. What medical facilities need credentialing?

Ans. Not just the practitioners, a variety of medical facilities need to maintain proper credentials to operate as a healthcare facility. The list includes Ambulances, Dialysis, Home Health Services, Independent Diagnostic Test Centres, Alcohol and Drug recovery centres, Hospice Care, Lithotripsy, Radiology/Diagnostic Imaging, Durable Medical Equipment, In-Home Care Services, Prosthetics/Orthotics, IV Home Infusion Therapy, Laboratories and Laboratory Collection Sites, Diabetes Education Providers, and Sleep Disorder and Sleep Study Clinics.

Q. What’s the role of a credentialing committee?

Ans. A credentialing committee works to maintain the reliability of the credentialing process by supervising and reviewing the application so that all parties meet the required standards.

Q. What’s the cost of Medical Credentialing?

Ans. The costs for medical credentialing may vary from specialty to specialty, from facility to facility, and from CVO to CVO. It usually ranges $200 – $300. Generally, medical facilities offer reimbursements (complete or partial) on successful completion of the credentialing process.

Medical credentialing helps set high standards for quality in the industry which directly improves healthcare services in the country.