Credentialing Corner

Comprehensive Credentialing Process Flow Chart for Healthcare Providers

Credentialing Process Flow Chart - Medical Billing and Credentialing Services Process Image

Credentialing can be referred to as a process that healthcare organizations tend to undertake in order to confirm the competency of healthcare providers. This is used to ensure that all healthcare providers are qualified and possess the relevant licenses, certificates, academic documents, letters of experience, etc. Through this process, it is ascertained as to whether the medical providers possess the capacity to cater to the needs and conform to the provisions pertaining to the pursuit of medical practice or not.

This article aims to discuss the Credentialing Process Flow Chart and all its measures. We will also examine the checklists that such programs must adhere to for efficient credentialing processes to be carried out.

The Provider Credentialing Process Flow chart

1- Application Submission

In this step, a medical provider presents all details of his credentials to the healthcare organization and submits an application form. Documents which are required to be submitted are licenses, complete CV, experience letter, qualifications, result cards, and diplomas.

2- Initial Review

In this step, the credentialing application form is assessed to make sure that all required papers are submitted. If some document is missing from the application form then the application is rejected. Candidates have to submit again with all required documents.

3- Primary Source Verification (PSV)

The details provided to the healthcare organization by the candidate are verified first. The certificates that are being checked by the credentialing specialist are:

  • Education verification: Credentialing specialist approaches educational institutions for the verification.
  • License verification: Licenses are checked with the help of state License boards.
  • Board certification: Certificates are verified through the coordination of specialty boards.
  • Work history: Details about previous jobs are verified with the help of experience certificates.

4- Background check

The history of the healthcare provider is checked to ensure that the provider has no legal issues, criminal background, malpractice history or national practitioner data bank query.

In this step, it is verified that the provider has had no legal issues in the past that may have influenced his personality to work. If his record claims any such type of issue then the healthcare department rejects his CV.

5- Credentialing committee review

  • Committee Composition: It includes healthcare providers, Credentialing specialists and other staff who are involved in the process of verification of credentials.
  • Committee Action: The procedure to review the provider’s documents, certificates, Licenses, CV and background.
  • Outcome: In this step, the credentialing application form of the medical provider is denied, accepted or approved with some specified requirements as a part of the agreement.

6- Approval / denial

The governing body of the healthcare organization overviews the opinion of the committee composition. The governing body of the healthcare department grants the official rejection or approval of the credentialing application of the healthcare provider.

7- Notification and contracting

  • Provider Notification: The official notification of the final decision of the healthcare organization is sent to the medical provider. The medical provider receives a joining letter with all the terms and conditions of the job if he is selected.
  • Contract Signing: In this step, a contract is signed by the healthcare provider.
  • Onboarding Process: After the selection, the provider attends an orientation program, which consists of training, initial lectures, and electronic health records (EHR) systems.

Key considerations in the credentialing process

There exist some considerations which should be opted for by healthcare organizations to maintain the smoothness of the credentialing process.

1- Timeless and efficiency

Credentialing is a prolonged and time-consuming procedure. It takes months to complete the verification of the documents. Healthcare organizations should take steps to uplift the efficiency of the process. With the use of electronic credentialing systems, the whole procedure can be completed in days instead of months.

2- Compliance and accreditation

The Joint Commission (TJC) and the National Committee for Quality Assurance (NCQA) are standards introduced by the accrediting bodies. Healthcare organizations must implement these standards to maintain the smoothness of the credentialing process. These laws give the concept of a regular and quick process of verification of the credentials without any delay.

3- Continuous monitoring

Credentialing is an unending procedure in which continuous monitoring of the medical providers takes place. Provider’s License is tracked from time to time. All details of the providers are updated after every certain period. It makes sure that healthcare providers maintain the standard of the credentials they provide before joining.

4- Data management and security

Management of data provided and ensuring security in the credentialing process is a difficult task because of the involvement of sensitive types of information, such as the provider’s personal and background details. Healthcare organizations must collect the necessary information to avoid uncertainties and risks. Strict access control mechanisms should be used for monitoring the sensitive data.

Credentialing software should adhere to Health Insurance Portability and Accountability Act (HIPAA) mechanisms to maintain the regularity of the process. By following the above steps, the chances of risks can be minimized.

Benefits of a comprehensive credentialing process

  • Enhanced Patient Safety: The credentialing process ensures that providers are qualified and experienced to deal with the patients, free from any legal and criminal cases. This procedure helps the patients to maintain their confidence in the physician.
  • Improved Organizational Reputation: It is up to the healthcare organizations how to build trust among the patients for their department. If the credentialing process is done without any error, then it automatically brings a patient’s positive reviews about the organization.
  • Legal and Regulatory Compliance: Any healthcare department, by adopting an accurate credentialing procedure, can comply with federal and state regulations. It helps to minimize the chances of legal issues and financial losses.
  • Better Risk Management: Verification of the documents, licenses, certifications, personal details, and criminal and legal issues is done in the credentialing process. This is done to put in action the qualified and disciplined medical practitioner. This process eradicates all kinds of risks.
  • Streamlined Operations: Access control system and use of specialized software help to maintain the smoothness of the credentialing process. The purpose of the streamlined operations is to lessen administrative and paperwork burdens.

Conclusion

The credentialing process is used by the healthcare departments to make sure that medical practitioners are qualified and experienced. In this way, only deserving medical providers get the chance to practice in the healthcare department. By adopting all of the above-mentioned steps of the credentialing process flow chart, the credentialing process can be improved. This process can be made more transparent, effective, and accurate by the use of streamlined operations, accreditation and updated software such as access control mechanisms. This process of verification builds a patient’s trust in the physician.