Provider credentialing is a multi-step process hospitals and healthcare organizations use to gather and verify practitioners’ qualifications to practice medicine. It’s performed on practitioners who are employed by the organization and those who are affiliated—for example, a physician practicing in the community who applies to be a part of the hospital’s organized medical staff. It is not typically conducted in doctors’ private practices.
What is the credentialing process for?
Credentialing is the starting point for hospitals to provide safe, quality healthcare to patients. However, done well, it also protects the hospital and all of its healthcare providers and staff. Credentialing is essential because it entails making sure that an applicant is who they say they are. It’s conducted before:
- A practitioner is allowed to provide care and/or services to patients in the hospital
- A practitioner is enrolled into participating insurance networks and considered “participating” in a commercial or government health plan
Credentialing’s role in the provider lifecycle
This provider credentialing process flow chart depicts where credentialing lies within the larger lifecycle of a provider in a hospital or healthcare organization.
Once a provider who newly presents to an organization is credentialed, onboarded, and practicing within the hospital or system, they undergo a modified credentialing process approximately every two years thereafter.
A hospital’s chosen, non governmental accreditation body (e.g., The Joint Commission, DNV-GL, NCQA) and/or state and governmental regulatory bodies (i.e., Centers for Medicare & Medicaid Services) dictate the guidelines for credentialing. These bodies also set guidelines for which practitioner types in addition to physicians must be credentialed. For example, physician assistants, certified registered nurse assistants, clinical psychologists, and other advanced practice professionals undergo credentialing and then the privileging process. An organization’s own bylaws and policies and procedures round out their own protocols for complying with accreditors and regulators, as well as meeting internal quality and safety goals and measures.
Credentialing workflow structure and tools
Because the credentialing process for healthcare providers is a time-consuming, administrative process that requires coordination of many data points and documents, many organizations either create their own internal Credentialing Verification Organization (CVO), or outsource to a qualified CVO. It’s best practice to ensure that the CVO is certified by the National Committee for Quality Assurance or Utilization Review Accreditation Commission. If not handled by a CVO, credentialing is the responsibility of the Medical Staff Services Department of the hospital—the office tasked with supporting the organized medical staff—or is the responsibility of credentialing staff within the Quality Department of a hospital. Provider enrollment professionals work within the CVO, hospital Medical Staff Services, or Enrollment Department at health plans to conduct credentialing for the purpose of enrolling providers into one or many health plans.
It’s nearly impossible to manage the multi-step process of credentialing for hundreds or thousands of practitioners without automation, so provider data management software is employed. A robust provider management system is capable of making data gathering, secure access, reporting, and ongoing compliance less burdensome for providers, credentialing staff, and the administrators and bodies that conduct final approvals, such as the Credentialing Committee and the Medical Executive Committee.
Credentialing technology solutions offer safeguards and efficiencies that include:
- Knowledge transfer and elimination or reduction of repetitive tasks, manual processes, and human errors that cause delays and increase costs.
- Ability for an increasing number of authorized departments and individuals hospital wide to access the provider data that medical credentialing professionals handle.
- Assurance that the hospital adheres to accreditation and compliance standards.
Credentialing process steps
If the applicant—physician, PA, CRNA, or advanced practice professional—will eventually seek clinical privileges in the hospital/healthcare system and his/her services will be billed for, they will undergo credentialing. Note that credentialing’s initial steps—application and primary source verification—are very similar whether they are conducted in unison or separately to:
- Credential to eventually grant clinical privileges (as credentialing professionals in hospitals do).
- Credential to enroll a provider into payers so the hospital can receive reimbursement for services (as enrollment professionals in hospitals, CVOs, or insurers/health plans do).
The key differences when primary source verification is conducted separately for these two goals is that more data may be collected for the credentialing-to-privilege process. The following steps depict an example medical provider credentialing process flow in a hospital facility when a credentialing software system is used to document actions and communications related to an application.
Step 1: The practitioner applies to the organization
The provider completes an online application at will or by request and attaches or links to all requested supporting documents. Data within the application itself and supporting documents give credentialing and enrollment professionals, human resources, and information they need to conduct their specific roles in the vetting and eventual onboarding of the provider.
Example items requested on a typical application include training and work history, educational background, professional references, and much more (See Step 2). The application contains instructions for the application about how far back to go when listing historical items, who may serve as a reference, and how many to list, etc. Contract software often works hand-in-hand with application functionality for any contract documents the provider must sign.
Although the burden is placed on the practitioner to submit a completed application, it’s the credentialing or enrollment professional’s role to follow up until all necessary data and documentation is received. Provider data management software uses alerts, reminders, and calendars to keep both parties on track.
Step 2: Information gathering & primary source verification occur
Primary source verification—the act of going directly to the issuer of the data or certificate whenever possible—may begin before or after a completed application is received depending on the healthcare organization’s policy and protocol. Note that a primary source may designate another organization as its agent in providing information to verify credentials.
PSV is perhaps the most critical step within credentialing and all of provider management. Credentialing and enrollment professionals often operate with very limited staff resources and under strict time constraints to help quickly onboard providers, so hospitals can serve patients and receive payment. They must be constantly on guard to identify impostors or individuals who exaggerate or fabricate professional qualifications to gain access to patients, creating significant risk.
The typical elements verified for provider credentialing include:
- Identity
- Criminal background check
- Education, residency, fellowship training
- Work experience/history
- National Practitioner Data Bank (NPDB) query for licensure and any sanctions or disciplinary actions
- Office of the Inspector General status (list of excluded individual/entities)
- System for Award Management status (SAM)
- Peer and professional references
- Health status/ability to perform privileges requested
- Board certification status
- Controlled Substances Registration (CSR) and U.S. Drug Enforcement Agency (DEA)
- Professional Liability Coverage – Claims history
- Credentialing software specifically created for medical credentialing provides automation to contact providers from within the software to gather missing information or documents, store provider documents and other information from primary sources, and leverage advanced tools, including web crawlers, to identify and obtain primary source verification. License monitoring automation checks for expired/suspended licenses and ensures that changes to a provider’s state or DEA medical license status will be accurately reflected in the provider record without manually cross-reference.
Step 3: Verified data flows to decision makers
Credentialing and enrollment professionals are key players in the initial steps of provider data management with the goals to:
- Collect applicants’ data
- Perform PSV according to the organization’s accreditation/ regulatory standards and bylaws •
- Submit completed data files to aid in informed decisionmaking
Data analysis to discover and point out any discrepancies or negative information that would impact an application is within the realm of credentialing. However, decision making about whether to onboard the practitioner to the medical staff and/or delineate clinical privileges does not typically occur in the credentialing phase. Rather, the Medical Staff Services Department receives a primary source verified application, begins critical analysis of the practitioner file, engages in discussion with the appropriate medical staff leaders (e.g., department chair, VPMA/CMO), and prepares a green-lighted practitioner file for eventual presentation to the Credentialing Committee, Medical Executive Committee, and/or hospital governing board.
Make credentialing about patient safety with a reliable solution
At worst, mistakes in credentialing can cause loss of life or other serious patient safety breaches, termination of accreditation, and negative credentialing lawsuits that affect an organization f inancially for years to come. Even minor complications of not “getting it right” in credentialing result in significant losses. The opportunity to use one technology for the entire lifecycle of a provider is available and helps ensure sound credentialing processes are followed from the start.
