What is the Credentialing Process for Physicians in the Healthcare Industry?

Getting a doctorate degree might not be enough for someone who wants to enter the medical healthcare field. Despite being equipped with certifications and meeting all the requirements of landing your first job at a hospital or starting your own practice, you would need to show the credentialing details to get paid for the services rendered. For this, you have to go through the credentialing process. If you have just cleared your medical study, then you might wonder what is the credentialing process for physicians?

In the medical industry, credentialing is the process of verifying the provided records that help doctors to start their practice. This would include hospital admitted privileges, malpractice insurance, educational certificates, work history, references, and more. It is a vital medical process that is required to maintain health safety standards for patients. Learn more about credentialing services and how practitioners should act accordingly in the article today.

What is the credentialing process for physicians?

Credentialing Process for Physicians

Healthcare provider credentialing or physician credentialing involves doctors and many other parties verifying the required information. At the same time, health organizations work to analyze the medical providers’ work to evaluate the reports that might be involved in malpractice or for other means.

All these reports are closely monitored by the healthcare facilities and also by the insurance companies that provide the list of approved healthcare practitioners for reimbursements. Credentialing process can be less extensive sometimes and is required for healthcare providers and nurses.

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Several types of medical credentialing for physicians are there, some of them are;

  • Insurance credentialing;

Also referred to as ‘getting on the insurance panel’ is used when providers’ credentials are being verified by a health insurance company. Whenever an insurance company adds a provider to its in-network provider list, they perform insurance credentialing.

  • Paperless credentialing;

The process of credentialing is performed through software that expedites the process of physician credentialing and eliminates the requirement of documents and papers to verify. In other words, the software verifies the provided documents from the issuers directly.

  • Credentialing for medical sales rep;

Also referred to as ‘vendor credentialing’, performed when healthcare organizations need to verify the training and background of vendors and sales reps when they want to enter a medical facility.

Documents and Information required for credentialing physicians

What is the Credentialing Process for Physicians

Depending on your state, healthcare facility, and insurance provider’s requirements, these are some of the information that you must need to provide as a healthcare provider;

  • Name
  • Previous/other names
  • Gender
  • Ethnicity
  • Mailing address
  • Email address
  • Daytime phone number
  • Citizenship information
  • Recent photograph
  • Current CV
  • Date of birth
  • Social Security number
  • Education and training
  • Residency
  • Licensing
  • Specialties
  • Specialty certificates
  • Qualifications
  • Career history
  • Patient age focus
  • Languages spoken
  • Hospital affiliations
  • Medical group affiliation
  • Practice address
  • Practice Tax ID Number
  • Practice phone number
  • Primary practice contact
  • National Provider Identifier (NPI) number
  • Board certification
  • Acceptance of new patients
  • Sanctions or disciplinary actions
  • Malpractice claims history
  • Proof of professional liability insurance
  • Continuing medical education documents
  • Peer references

Standards for a credentialing process for physicians

The Joint Commission on Accreditation of Healthcare Organization and the federal Centers for Medicare & Medicaid Services (CMS) both provide the standards for physician credentialing. Hospitals and practices that do not comply with the standards and the guidelines provided by CMS are not eligible for reimbursement from Medicare and Medicaid. In the same way, the Joint Commission on Accreditation of Healthcare Organization recognizes hospitals and facilities only that follow their guidelines. Although states regulate their tailored regulations, many hospital facilities follow regulations provided by the Joint Commission on Accreditation to be acceptable at CMS as well.

In addition, to increase accreditation, healthcare organizations follow guidelines for credentialing provided by other groups as well. These groups include;

  • Utilization Review Accreditation Commission (URAC)
  • The National Committee for Quality Assurance (NCQA)
  • Det Norske Veritas (DNV)
  • The Accreditation Association for Ambulatory Healthcare (AAAHC)

What is the credentialing process for physicians?

The credentialing process for physicians involves mainly three steps which are explained as,

1. Gathering information

The health insurance company or healthcare facility asks physicians for the required information including background, educational certificates, licenses, etc. The physician is allowed to provide the required documents through email, a questionnaire, or through software.

Many times, providers hire a third-party credentialing service to gather and verify the information to expedite the process.

2. Check the information

Oftentimes, healthcare facilities work to connect with the corresponding agencies to verify the information such as licensing agencies, certification or training institutes, medical schools, etc.

When using software for physician credentialing, insurance companies or facilities continuously check the provided information through entities and agencies that provide their information online for background checks.

Third-party credentialing services also work with healthcare facilities to verify the information. Having the updated software, they help in credentialing by performing a check of licenses, expiring date, malpractice information available online, and re-checking if required.

3. Awarding physician with credentials

Once the background check is completed and organizations do not find negative issues, they grant the credentials of working to the physician. As for insurance companies, if they are also satisfied with the outcome, they will approve the physician to be reimbursed through the in-network list of providers. This is the list that defines who will be paid for treating patients having CMS health insurance.

Ending notes

The physicians’ credentialing process is an important aspect of getting approved for reimbursements and paid for treating patients by different entities. Physicians have to be credentialed before they start their practice.

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