Medical credentialing is a professional process that helps to establish and maintain effective standards throughout the medical community. Its central goal is to promote patient confidence and ensure the highest quality of care. Though it also plays an important role in verifying a practitioner’s license, their education, and streamlining other important information necessary to provide services and work with insurance companies.

An organization confirming an individual’s medical credentials will typically contact the certification boards and licensing agencies. This might also include contacting hospitals, clinics, and other employers to confirm the individual’s work history. In some cases, this process might also include investigating specialty certificates.

Medical credentialing is typically included in any new hire process. Though it might also be conducted at periodic intervals to conform to the specific regulatory standards. Especially in the case of a specialty where continuing education is part of the licensing requirements. This might also include communicating with larger institutions such as The Centers for Medicare and Medicaid Services. the Joint Commission or the National Committee for Quality Assurance.

Medical Credentialing Has 2 Phases

The medical credentialing process typically has two phases.

Verifying Competency

The stage looks at things like this individual’s education, their training, continuing education certificates, work experience, and active licenses. As well as any past lapses in licensing.

Privileging

This phase essentially grants approval for a healthcare provider to perform specific treatments and procedures based on the competency information.

The Benefits of Medical Credentialing

Medical credentialing goes beyond essential quality assurance in the medical industry. It also provides clinics, hospitals, and growing private practices with the confidence they need to hire qualified staff. This further has an influence on insurance companies, both in the rates they offer to patients as well as how they assess medical malpractice insurance to practitioners.

At the same time, practitioners appreciate how medical credentialing privileges make it easier for them to accept clients who have sufficient coverage from insurance companies. This allows doctors, nurses, specialists, and other medical professionals to expand the number of patients in their care, without worrying about losing time to claim rejections or claim denials.

Of course, the patients can rest safe in the knowledge the practitioners are providing them with the highest quality of care using the medical industry’s rigorous best practices.

Who Needs Medical Credentialing?

Medical credentialing is now seen as an industry standard for a wide range of general practice medical professionals and specialists.

This includes:

  • General Physicians
  • Dentists & Orthodontists
  • Ophthalmologists & Optometrists
  • Physical Therapists
  • Physician Assistants
  • Podiatrists
  • Practicing Nurses
  • Chiropractors
  • Counselors
  • Family Therapists
  • Marriage Counselors
  • Social Workers
  • Psychologists & Psychiatrists
  • Behavioral Therapists

Can A Practitioner Treat Patients During the Credentialing Process?

As a quality assurance and verification process, a person undergoing the medical credentialing process cannot treat patients until the results have been certified. This regulation is designed to ensure that all patients receive only the highest quality of care from practitioners who are truly qualified to provide it. This requirement also helps to reduce liability risk for clinics, hospitals, and other medical institutions.

Do Medical Students Need Medical Credentials?

Technical medical students, including fellows and those in residency, are under the guidance of a credential professional such as an attending or other credentialed provider. They are only allowed to work within the scope of their training and provide treatment under the guidance of their program. This is one of the rare exceptions, as they have not technically completed their training to receive official privileging.

What Institutions Need Credentialing?

A wide range of medical institutions needs credentialing and medical privileged practitioners to provide care to patients. This includes:

  • Ambulances
  • Diabetes Educators
  • Dialysis
  • Drug & Alcohol Recovery Centers
  • Home Health Services
  • Hospice Care
  • In-Home Care Services
  • Independent Diagnostic Testing
  • IV Home Infusion Therapy
  • Laboratories
  • Lithotripsy
  • Medical Equipment Provider
  • Prosthetic & Orthotic Clinics
  • Radiology & Diagnostic Imaging Centers
  • Sleep Disorder & Sleep Study Clinics

What Is The National Commission For Quality Assurance?

Also known as NCQA it is an independent, nonprofit organization that specifically evaluates and directly reports on the quality of healthcare organizations before issuing them credentials. This includes:

  • Preferred Provider Organization
  • Managed Behavioral Healthcare Organizations
  • New Health Plans
  • Doctor Organizations
  • Managed Care Plans
  • Credentials Verification Organizations
  • Disease Management Programs

What Is The Joint Commission?

More commonly known as TJC they are an accrediting organization that serves to maintain the highest standards and best practices of the United States healthcare industry. Hospitals and clinics will voluntarily submit themselves for TJC accrediting surveys at three-year intervals.

What Are Centers for Medicare and Medicaid Services?

The CMS is an agency of the Federal Government under the United States Department of Health and Human Services umbrella. It has a wide range of responsibilities, including oversight of quality standards in long-term care facilities as well as clinical laboratories.

Though their most common task is working with state and county governments to administer Medicaid, as well as the Children’s Health Insurance Program, and maintaining health insurance portability standards.

What Is Primary Source Verification?

Primary source verification plays an essential role in preventing any type of fraud in the medical credentialing process. They work directly with the Board of Medicine to confirm all medical licenses and adhere to strict standards for certified healthcare facilities.

How Does A Provider Obtain Their Medical Credentials?

The medical credentialing process can vary depending on the facility and the specialty. Though some core parts are found throughout all verification and privileging phases. Most institutions have a preferred credentialing service that they use. Some hospitals and larger clinics with multiple specialists might have more than one credentialing service on retainer.

The application typically starts with submitting documents to a CVO via mail, fax, or email. At that point, the credentialing services professionals will start the verification process. This includes preparing a file for review by the credentialing committee. Once they have completed the process the practitioner’s application file will be sent to the medical facility, along with a letter explaining why they approved or denied the application.

What Is a Credentialing Committee?

A credentialing committee is a body of experienced individuals who are tasked with maintaining the integrity of the medical credentialing process. This includes oversight of the application process as well as ensuring that all parties meet the required standards. It is typically made up of physicians from varying specialties, as well as a chairperson and a liaison staff.

How Long Does The Medical Credentialing Process Take?

Here again, it can depend on the medical institution as well as the practitioner applying for medical credentials. In some cases, where a minimal amount of background information needs to be gathered, the process might only take 7 to 10 days. Though in the case of a specialist, or an application that was filled out incorrectly, the medical credentialing process might take several weeks to several months.

Ideally, if you are someone who is applying for medical credentials it’s wise to plan on initiating the medical credential application 90-days before your intended start date. This will give sufficient time for every stage of the process to carry through normally. If there is an issue or a minor clerical issue with the application, there is time to have it corrected without undue complications.

There are things a medical institution, and the applicant can do to help streamline the process. This includes:

  • Including the practice and remit addresses
  • Filing with the Taxpayer Identification Number
  • Include the National Provider Identifier-2
  • Verify the phone and fax number
  • Include a completed W9 for the individual or the practice
  • Include your IRS 147C Letter

How Much Does Medical Credentialing Cost?

The cost of the medical credentialing process can vary based on the institution as well as the specialty. Different credentialing services might also have different fee structures. If you are a medical practitioner applying for medical credentials you can expect a ballpark cost of between $200 to $300 per provider per application. Depending on the medical institution you are applying for, they might cover these costs or reimburse you upon successful completion.

Is It Possible To Track The Medical Credentialing Process?

Some medical credentialing services use cloud-based applications that will allow you to monitor the proves via an app or an email. It can be especially handy if your application has accidental errors or other complications. Though this is based on the service that the institution uses and the institution.

How Often Are Medical Credentials Updated?

This can vary from institution to institution. Most will require a provider to update their medical credentials every one to three years. Especially if their medical license requires a certain level of activity or continuing education. Many specialties will place an expiration date on a provider’s medical credentials to ensure that they are maintaining the highest levels of professionalism. If there is a lapse, then the practitioner needs to apply for reinstatement.

Post Medical Credentialing Management

Once a medical practitioner has been credentialed and their information has been provided to the institution for approved hiring, they can enter into a contract with an insurance company. This allows them to bill and is reimbursed as an in-network provider. This is especially important for small practices that sometimes need to handle their own medical billing or those who outsource to a third-party medical billing service.

What Is Recredentialing?

Most medical institutions require re-enrollment or re-credentialing every one to three years. Practitioners typically receive a letter informing them well in advance of the deadline. Failure to reapply promptly could lead to a lapse or suspension, which would require a reinstatement process. Many times an institution will cover the cost or reimburse the individual practitioner upon completion of the recredentialing process.