Everything You Need To Know About Physician Credentialing

It takes more than a medical degree to practice medicine. Even after someone goes through all the schooling, passes their medical boards and obtains a license to practice, physician credentialing still stands between a provider and patients — no matter where they are in their career. It’s an ongoing, critical part of practicing medicine, and the onus is on healthcare organizations to make sure they’re staying abreast of physician credentialing.

Here’s an overview of the process: what it is, why it’s important and how software can help simplify it, to ensure every physician practicing at your facility is doing so legally. 

What Is Physician Credentialing?

Physician credentialing is the process of verifying and assessing the qualifications, training, experience and professional background of physicians and other healthcare providers. It’s a crucial step in ensuring that healthcare professionals meet the regulatory requirements to practice medicine.

Credentialing ensures that providers meet the necessary standards of competency, professionalism, and ethical conduct before they start working with patients. The process involves collecting and verifying relevant documents, conducting background checks, contacting references, and assessing the information gathered. 

This includes primary source verification of various aspects, including:

• Education and training. Verification of medical school degrees, post-graduate training programs, and any specialized certifications or fellowships.
• Licensure. Confirmation of the physician’s medical license, including its validity and any restrictions or disciplinary actions associated with it.
• Board certification. Assessment of board certifications obtained by the physician from recognized medical specialty boards.
• Work history. Review of the physician’s employment history, including previous positions held, clinical experience, and any gaps in employment.
• Malpractice history. Investigation of any malpractice claims or disciplinary actions filed against the physician, including settlements or judgments.
• References. Checking references provided by the physician, such as recommendations from colleagues, supervisors, or mentors.
• Hospital privileges. Evaluation of the physician’s request for hospital privileges, including their ability to meet specific requirements and standards.
• Quality measures. Examination of the physician’s performance data, such as patient outcomes, adherence to clinical guidelines, and peer reviews.

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Why Is Physician Credentialing Needed?

Physician credentialing helps protect patients by ensuring that healthcare providers are qualified and competent to deliver high-quality care. It also allows healthcare organizations to establish networks of trusted physicians and maintain appropriate standards for reimbursement, insurance coverage, and compliance with regulatory requirements.

Here’s a look at some of the immediate benefits that come with proper physician credentialing:

• Patient safety. Credentialing helps protect patient safety by ensuring healthcare providers have the necessary qualifications, training, and experience to deliver competent, quality care. By verifying credentials, organizations can identify any potential issues — such as malpractice history or disciplinary actions — that may impact a physician’s ability to provide safe care.
• Quality assurance. Credentialing helps maintain and promote high standards of healthcare quality. By assessing a physician’s education, training, board certifications, and performance data, organizations can ensure physicians meet specific criteria and adhere to professional standards. This helps establish a network of competent healthcare providers and improves the overall quality of care provided to patients.
• Legal and regulatory compliance. Credentialing is required by laws, regulations, and accreditation bodies. It ensures that healthcare providers meet the legal and regulatory requirements necessary to practice medicine. Compliance with credentialing standards is essential for healthcare organizations to receive reimbursement and meet regulatory obligations.
• Insurance coverage and reimbursement. Insurance companies require credentialing as a prerequisite for physicians to participate in their networks and receive reimbursement for services rendered. Credentialing helps insurers assess the qualifications and competence of healthcare providers, ensuring that they meet specific standards before allowing them to provide care to insured patients.
• Hospital privileges. Many hospitals and healthcare facilities require physicians to undergo credentialing before granting them privileges to practice within their facilities. This process helps to ensure physicians meet the hospital’s standards for delivering safe and effective care to patients. Credentialing is often necessary for physicians to admit patients, perform procedures, and access hospital resources.
• Professional reputation. Credentialing contributes to establishing and maintaining a physician’s professional reputation. By verifying credentials and conducting background checks, organizations can identify any discrepancies or issues that may affect a physician’s reputation. Credentialing helps promote transparency and trust among patients, colleagues, and across the healthcare community.

What Are the Steps of Physician Credentialing?

Physician credentialing isn’t something that happens overnight. Because it involves verifying information from multiple different sources, the process can take weeks or longer. Here’s a brief overview of the steps involved:

• Primary Source Verification. A credentialing expert verifies the accuracy and authenticity of the information provided by the physician. They directly contact the primary sources such as medical schools, residency programs, licensing boards, and previous employers to confirm education, training, licensure, and work history.
• Background Checks. A comprehensive background check is conducted on the physician. This includes criminal background checks, verification of any history of disciplinary actions or malpractice claims, and verification of any actions taken against the physician’s medical license.
• Peer References. The physician provides references from colleagues, supervisors, or other healthcare professionals who can vouch for their competence and professionalism. The credentialing specialist contacts these references to gather information regarding the physician’s clinical skills, ethical conduct, and overall performance.
• Credentialing Review. Credentialing and compliance teams assess the physician’s qualifications, experience, and training to ensure they meet the organization’s standards and requirements.
• Decision and Notification. Pending review, a decision is made regarding the physician’s application. They’re then notified of the decision, whether it is an approval, denial, or request for additional information.
• Recredentialing. Once a physician is approved, their credentials are periodically reviewed to ensure they maintain the necessary qualifications and meet the organization’s standards. This process, known as recredentialing, typically occurs in regular intervals annually or every two years, depending on the organization’s policies.

Should I Use a Credentialing Service?

Not every healthcare organization will handle credentialing in-house. If you’re curious about the efficacy of using a fully-managed credentialing service, consider these common reasons when it makes sense:

“My facility is growing the number of providers”

The more providers you need to credential and recredential, the larger the burden compliance tracking becomes. If you don’t have a robust tracking and organization system set up in-house, partnering with a credentialing service can be a smart move. 

“I’m new to the position and there is no process in place”

A fully-managed credentialing service is a great option if you’re new to your role. A team of dedicated credentialing specialists can help you to get a process in place and ensure that you avoid costly delays.

“Credentialing staff are already overwhelmed”

Trying to manage a massive credentialing workload with just a few specialists is a recipe for compliance problems. While you fine-tune processes, bring on more staff, or transition to a digital credentialing software solution, outsourcing can serve as a good stopgap. 

“My facility is so small; we don’t need a full-time credentialing specialist”

One of the biggest mistakes organizations make is minimizing credentialing. No matter how small your organization is, credentialing is still of the utmost importance. If you’re not sure how to approach it, a credentialing service is often a good route. 

MedTrainer Optimizes Credentialing: In-House or Outsourced

Whether you prefer to keep your credentialing process in-house or are looking to outsource, MedTrainer can help with both. For organizations that decide to keep credentialing in-house and want to streamline the process to stay on top of compliance, MedTrainer’s Credentialing Software is the tool you need. With centralized documentation capabilities, workflow automations, and direct access to credentialing records, it’s the perfect way to prioritize and optimize credentialing for your providers. If you need to outsource all your credentialing needs, MedTrainer’s team of credentialing specialists can do it all for you, from start to finish and beyond.

Schedule a demo today and see for yourself how easy it is to stay on top of physician credentialing with MedTrainer!