What Is the Credentialing Process?

Amber Ratcliffe
Group of doctors smiling

When someone is hired for a job, there are a variety of steps included in the onboarding process. For healthcare professionals, the nature of their work as caregivers demands even more scrutiny. The credentialing process — also called provider credentialing, physician credentialing, or medical credentialing — is a critical part of onboarding. It’s the most important step between hiring a caregiver and putting them to work. 

The National Committee for Quality Assurance (NCQA) has established a set of standards that currently act as a guideline on how to credential health care providers. These include written policies and procedures, verification of credentials, primary source verification, ongoing monitoring, and data collection and reporting. Accreditation organizations also have additional credentialing standards that must be followed to earn accreditation.

Let’s delve deeper into the process of credentialing, to shine a light on both what’s involved and how healthcare organizations can streamline the process (while maintaining high standards). 

What’s Involved in the Credentialing Process?

The credentialing process is lengthy and specific — but for good reason. Through credentialing, healthcare organizations get a clear, unbiased, factual understanding of a provider’s ability to treat patients. Here’s a look at the critical steps involved in credentialing:

  • Privileging. Privileging involves the collection and review of a provider’s documentation to determine if they’re worthy to provide care to patients within a specific institution. All providers must receive privileges at the facility where they will see patients before they begin practicing. 
  • Payer Enrollment. Providers, groups, and facilities must be enrolled with every payer they accept insurance from — again, before they start seeing patients. With an average of 5 – 10 payers per provider/group/facility, this can be a time-consuming and tedious step that needs to start early in the credentialing process. 
  • Primary Source Verification. Primary source verification involves contacting original sources — such as educational institutions, licensing boards, and certification bodies — to confirm the authenticity and accuracy of the documents and qualifications provided by the provider. This can also include verifying Drug Enforcement Administration (DEA) and Council for Affordable Quality Healthcare (CAQH) training.
  • Work History and Reference Checks. The credentialing process also involves verifying the work history of the provider, including previous employment positions, job responsibilities, and professional references. This helps assess the provider’s experience and reputation within the healthcare community.
  • Background Checks. Comprehensive background checks help rule out any criminal history, malpractice claims, disciplinary actions, or other records that might send up red flags. This is a crucial step in ensuring patient safety and protecting against potential risks.

Watch this short video for a glimpse into an efficient credentialing process.

The culmination of the credentialing process can result in full approval, provisional approval, or denial of a provider. And, once credentialed, providers are subject to ongoing monitoring and recredentialing at specified intervals. This ensures that they maintain their qualifications, adhere to professional standards, and continue to meet the requirements for practicing in their respective roles.

Why Does the Credentialing Process Take So Long?

One of the biggest issues many healthcare organizations have with credentialing is that it requires an incredible time commitment. There are several reasons why this process often takes a significant amount of time. 

  • Primary source verification requires contacting various institutions and organizations to authenticate the provided information. You’re often at the mercy of these institutions to reply to you, and there are often delays or discrepancies in documentation.
  • Background checks are equally as time consuming. While it’s easy to request criminal background reports, getting the report can take weeks. Moreover, following up with references isn’t always as simple as making a call. 
  • The administrative burden of credentialing adds to the time it takes to sign-off on providers. Coordination and communication can take time — particularly if there are any additional inquiries or clarifications needed.

The length of time it takes to credential a physician comes down to how quickly you can obtain necessary information and how organized you are in following the credentialing process. It’s why many healthcare organizations use credentialing software or credentialing services to expedite the process. 

5 Tips: How To Select a Credentialing Service

With so many roadblocks and potential delays, a credentialing service or software is often a wise investment. They allow healthcare organizations to focus on patient care and day-to-day operations, while a partner manages all aspects of the credentialing process in the background.

Here are a few tips to keep top-of-mind when selecting a credentialing service or software:

1. Visibility Into the Process

Look for a credentialing service that tracks the entire process in an online platform, so you always know the status and can provide updates to leadership without a delay. Important items you’ll need access to, include:

  • Call reference numbers for prompt follow-up
  • Initial and recredentialing dates, to stay apprised of deadlines
  • Copies of payer approvals for record-keeping

2. Electronic Document Submission

It’s so much easier for providers if they’re able to electronically upload documents to a centralized platform. Make sure your credentialing service offers this option — and that they’re using a secure portal! It’s the best way to stay organized, especially if you have a growing number of providers to credential and keep track of. 

3. Proven Workflow

Standardization is crucial in eliminating errors. Work with a credentialing partner that not only understands the process, but who customizes it for your organization and establishes a structured, repeatable framework. This will lower the chances of missed steps or delays in credentialing caused by missing documentation. 

4. Familiarity With State Regulations

Every state has different requirements and insurance providers use different enrollment applications. To perform credentialing successfully, you’ll need to work with a service that offers a similar level of specificity. Check to make sure they’re compliant with state regulations where you provide service, and that the credentialing for those providers reflects compliance.  

5. Network Analysis Performed

To avoid duplicate profiles with payers, a credentialing service should conduct due diligence in running a network analysis. This enables you to see if your provider is enrolled and if their enrollment is active. By starting every process with a network analysis, you’ll identify whether a provider has already been enrolled with a payer and verify the recredentialing date.

Consider MedTrainer Credentialing Services

MedTrainer’s team of regionally-focused credentialing specialists offers a comprehensive solution for healthcare organizations seeking to navigate state-specific rules and streamline their credentialing processes. Our proven workflow for document collection, accuracy, and efficiency — as well as handling of recredentialing, re-enrollment, and continuous monitoring — further enhances the convenience and reliability of our services. 

By eliminating interruptions and staying up-to-date on state requirements, our specialists facilitate a faster, more efficient credentialing process. Schedule a free demo today and see for yourself how simple the credentialing process can be with the right partner! With thousands of organizations relying on our expertise, MedTrainer ensures peace of mind nationwide.