Provider Credentialing 2024 Guide

Clinician looking at papers

Healthcare providers have always been seen as vital pillars of our society, often risking their own well-being to ensure the health and safety of others. Physicians and nurses have consistently ranked among the most-respected professions, demonstrating unwavering commitment and dedication to their field. Patients place their faith in a comprehensive system of checks and balances that allows providers to safely deliver healthcare services and procedures. However, for those wishing to work in or affiliate with a hospital or healthcare system—and to be reimbursed for services rendered—they must undergo a complex process known as provider credentialing.

What is provider credentialing?

Although we think of the provider/patient relationship as one-to-one, multiple administrative functions in hospitals contribute to, and share, the responsibility of ensuring that the clinician delivers safe, high-quality care. Provider credentialing is focused on just one slice of that duty: vetting providers’ backgrounds and current competency levels to ensure they are qualified for their roles. 

The provider credentialing process is a prerequisite to an organization's ability to grant providers’ clinical privileges to do anything from performing a patient history and physical, to open-heart surgery, to prescribing drugs in a hospital setting.

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. Credentialing is not typically conducted in doctors’ private practices. For more on this, download this eBook that outlines the process from start to finish.

Managed care and insurance companies (i.e., payers—both private and government) also conduct provider credentialing, either independently or in concert with a hospital/healthcare system, often using a credentialing verification organization (CVO).

How does provider credentialing work?

The provider credentialing process is completed in stages by a provider organization’s or payer’s credentialing department, or an internal or third-party CVO. Credentialing staff:

  • Gather information from many sources, including the provider—a step that often includes significant follow-up efforts.
  • Primary source verification (PSV) of the data and the documents collected.
  • Assess and identify gaps, discrepancies, or red/“pink” flags of any kind.
  • Make recommendations regarding credentialing—whether for enrollment with a payer/payers, or for consideration of clinical privileges.

Gathering provider information consists of collecting all necessary documentation and certifications. Once this step is completed, the information is checked for accuracy and legitimacy. The specific data and documents that are collected are fairly uniform, although they ultimately depend on which regulatory and/or accreditation body/bodies the organization follows. Examples include the Centers for Medicare & Medicaid Services, individual state oversight bodies, The Joint Commission (TJC), The National Committee for Quality Assurance, DNV, the National Association for Healthcare Quality, Utilization Review Accreditation Commission, and many others. 

Primary source verification 

Going to the primary source, or issuer of the data or document, is essential, because secondary sources of information might be inaccurate, unreliable, or biased. Consider that today's technology can easily enable healthcare providers or impostors to exaggerate or fabricate qualifications to gain patient access. As a result, PSV is a critical stage of credentialing. If done poorly, the results can range from patient harm or death to negligent credentialing lawsuits in the millions. Typical steps of PSV might include:

  • Verify the provider’s notarized government issued identification, criminal background status, and OIG status
  • Review the application (and privilege requests if applicable)
  • Verify the provider’s education, residency, fellowship, primary source schooling, and training programs
  • Confirm the provider’s board certification status (if applicable)
  • Verify state license, controlled substances registration, DEA
  • Verify professional liability coverage, and claims history
  • Conduct National Practitioner Data Bank query
  • Confirm provider’s work history
  • Obtain and verify references (including program director, department chair)
  • Check NCQA, TJC, or URAC-required verifications such as training and education, licensure, malpractice history
  • Check health plan specific requirements, such as SSN death master list, board certification, etc.
  • Check state-specific primary source verification requirements

To ensure accuracy, the credentialing professional or function collectively assesses the entire provider data file once all material has been gathered. The goal is to guarantee, to the extent possible, that all data reflects the full portrait of a provider. In other words, are they fit clinically, personally, and professionally to work in the healthcare organization? The credentialing procedure looks at the individual's background, education, experience, training, history, licensing, and ability to practice medicine. 

Credentialing professionals or CVO staff rarely make decisions about credentialing. Rather, they provide the data and key insight for leaders in administrative roles or on committees to move the provider forward in the process.

Provider credentialing could be denied or delayed if any one of these steps is not completed correctly. An error in the process could prove costly for the organization or applicant, and result in them having to start the process over, or even be eliminated from attaining their desired position. Mistakes or inefficient provider credentialing also slows the ability of the provider organization to bill for provider services, negatively impacting cash flow in the revenue cycle. Making sure all information is verified and keeping a close eye out for gaps in the applicant’s background are two easy ways to avoid giving credentials to an unworthy candidate.

Who’s responsible for credentialing?

As noted, both provider organizations and payers perform credentialing, though their processes may differ slightly. 

  • For hospitals and healthcare systems, credentialing initiates the gathering of data that will be used eventually for both clinical privilege delineation and enrolling providers into payer panels, so the organization can be reimbursed for services. 
  • For private payers (e.g., Cigna, Humana, UnitedHealth) and government payers (e.g., Centers for Medicare & Medicaid Services), credentialing helps to set and adjust the number of providers in their networks and to determine their qualifications. The goals: to save on total healthcare costs, yet ensure their ability to deliver the healthcare benefits promised to enrollees.

However, providers, too, play a role in credentialing. Before undergoing the credentialing process at the healthcare organization(s) where they intend to practice or become affiliated, providers themselves take many steps, including:

  • Complete their general medical education for their future role
  • Undergo specialty training and/or complete fellowships to gain the requisite technical skills needed to perform in their profession
  • Become licensed by their state and/or other specific professional organization
  • Apply to the healthcare organization(s) where they wish to practice/affiliate

Then, it’s the policy and a best practice for many organizations to “place the burden on the provider” to produce—in a timely way—all of the material needed for credentialing. 

Who is provider credentialing for?

You may think the question, “Who is provider credentialing for?” has an easy answer—the patient. But really, the process is to guarantee that all parties work in a safe, high-quality setting. Providing a safe, friendly, and professional healthcare environment starts with provider credentialing and extends to fellow clinician and all healthcare staff. Providers must go through the credentialing process initially to help foster this safe environment.

Then, approximately every two years, they are re-credentialed to ensure ongoing competence. All throughout those two years, performance data is collected on providers at regular intervals to inform future competence decisions. Without the credentialing process, healthcare facilities jeopardize the safety of all parties and could run into legal issues. 

Has provider credentialing changed?

While major regulatory and accreditation requirements regarding credentialing do not occur very often, technology, integration, and expectations for high-level customer service (patient and provider) are radically changing the process, in the following ways:

Credentialing and payer enrollment are integrating 

In hospitals, enrollment only recently emerged as a function requiring administrative resources and staff on a scale equal to that of medical services. Several factors caused this, including the shift to employing providers, hospital and health system closures, mergers, and consolidations; and the urgency to recover all possible reimbursements under value-based care arrangements. As enrollment’s importance grows, healthcare leaders see synergy between IT and credentialing, and an opportunity for efficiency. 

Credentialing is going paperless

The exchange of paper is not secure and digital exchanges allow for easier knowledge transfer. In addition, space/storage and environmental considerations are fueling the move to digital provider data management systems.

Cloud technology aids remote credentialing work

Working from home and importing and exporting data and documents from anywhere, via any electronic device, is a scenario that’s here to stay. Software as a service (SaaS), or cloud technology, secures information and enables remote connectivity for any user, including providers, with any level of permissions granted. symplr’s Application Manager tool, for example, facilitates the completion and submission of documents required for initial or reappointment online via a secure website, eliminates paper credentialing packets, and provides an efficient way to share a and reuse data that already exists in the system.

Credentialing data is the source of truth for more users

The provider data medical credentialing professionals handle is being accessed and used by more and more authorized departments and individuals. Healthcare governance, risk management, and compliance (GRC) rely on millions of data points that stream across credentialing, privileging, quality/safety, and enrollment processes. 

The bottom line about provider credentialing

The provider credentialing process consists of gathering hundreds, or thousands, of data points, data review, and assessments of character—and errors can be costly to the provider, the organization, and ultimately patients. It starts with the end in mind: Every healthcare organization strives to deliver the highest quality, safest healthcare possible to patients while protecting all participants. Multiple organizational functions contribute to, and share, the responsibility to deliver on this goal. With that in mind, one can fully understand what provider credentialing really is and why it’s so important. Consistently following credentialing best practices ensures that our healthcare workers are thoroughly educated and trained to provide the quality care our healthcare community strives for.

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