What is provider credentialing?
Credentialing is the detailed process of verifying a healthcare provider’s qualifications, competency & history. It ensures clinicians are qualified to safely and effectively perform their duties supporting both patient safety and quality care.
For organizations and providers, credentialing is essential to healthcare operations. Without it, hospitals hospitals and ambulatory surgery centers cannot grant clinical privileges or receive reimbursement for services. Insurance companies also rely on credentialing to determine whether providers meet the standards required to participate in their networks.
Who needs credentialing?
In essence, credentialing will apply to any licensed healthcare professional who plans to deliver patient care and submit claims to insurance companies must be credentialed. In addition, provider types who wish to have privileges at hospitals or surgery centers must also complete the credentialing process.
While some of the steps in the credentialing process for billing to insurance companies and obtaining privileges overlap, the end result is different based on the providers specialty or request.
What are the steps of provider credentialing?
- Gather provider information
- A detailed application is obtained from the provider that includes, educational certificates, licenses, work history, malpractice and professional references.
- Primary Source Verification
- To remain compliant and ensure accuracy of records, primary source verification is a critical step in the process. This involves cross checking information directly with the original issuer. This ensures the authentically of the provider qualifications.
- Medical education and training
- State licensure and DEA
- Board certifications
- Malpractice & Work History
- Professional References
- To remain compliant and ensure accuracy of records, primary source verification is a critical step in the process. This involves cross checking information directly with the original issuer. This ensures the authentically of the provider qualifications.
- Data Review
- Once all information is gathered, a dedicated credentialing staff, reviews the collected information and reaches out to the provider to discuss any gaps or discrepancies.
- Final Review by Committee
- A committee of leaders, who meet the organizations bylaws, will assess the final application presented by the credentialing staff and provide a decision on the clinical privileges.
