Spotlight on the Importance of Medical Credentialing

Joyce Siow-Yazzie
Doctor examining a patient

Not only is it important to deliver the best care to patients, it’s vital to be transparent and accountable for the people providing that care. That’s why medical credentialing is such a crucial part of compliance for healthcare organizations and the providers working within them. 

Unfortunately, medical credentialing isn’t an easy task — and it’s one that’s ongoing. To make sure your organization stays on-the-level, it’s important to have experts, systems, and software that enable accountable credentialing. Here’s a look at what, exactly, that means and how to achieve it.

What Is Medical Credentialing?

Medical credentialing — also known as physician credentialing or provider credentialing — is the process of verifying and assessing the qualifications, training, and professional background of healthcare professionals. It’s a crucial step in getting providers into the field, and it ensures they meet the required standards and have the necessary qualifications to provide quality patient care.

Medical credentialing typically involves primary source verification of various documents and information related to a healthcare provider’s abilities, including: 

  • Education and training
  • Licensure and certifications
  • Work history
  • Malpractice history
  • Professional references 

The process is conducted by credentialing specialists — either in-house or outsourced — to assess the competence and eligibility of providers. It’s an absolutely essential part of compliance management.


WEBINAR: Credentialing Is Evolving. Are You?

Why Is Medical Credentialing Important?

There are numerous important objectives behind the process of medical credentialing — many of them rooted in compliance. Here’s a look at some of the reasons it’s so important, and why healthcare organizations need to prioritize ongoing credentialing:

  • Verify the education and training of healthcare professionals. This includes confirming their medical degrees, specialty training, and completion of residency and fellowship programs.
  • Validate licensure and certifications. Credentialing organizations verify that healthcare providers hold valid and unrestricted licenses to practice medicine and any additional certifications relevant to their specialties.
  • Review professional practice history. This involves checking for any disciplinary actions, malpractice claims, or adverse events related to the provider’s practice.
  • Assess professional competence. Credentialing experts evaluate the provider’s clinical skills, experience, and adherence to professional standards.
  • Confirm hospital privileges. For physicians, credentialing includes evaluating their qualifications to practice at specific hospitals or healthcare facilities and granting them clinical privileges based on their expertise and training.

Understanding How Credentialing Works

Credentialing involves several steps and typically follows a standardized process that’s rooted in primary source verification. Here’s a brief overview of how credentialing works:

  1. Application. The healthcare provider submits an application. This application includes personal information, educational background, work history, licensure details, certifications, and other relevant documentation.
  2. Primary source verification. A credentialing specialist performs primary source verification to confirm the accuracy of the information provided in the application. This involves directly contacting the sources of the information — such as medical schools, licensing boards, training programs, and professional organizations — to verify the information provided.
  3. Review and evaluation. The credentialing expert reviews the verified information by assessing the healthcare provider’s qualifications, experience, and adherence to standards. They evaluate factors such as educational background, training, work history, malpractice history, disciplinary actions, references, and any other relevant criteria.
  4. Peer references. Healthcare organizations often require peer references from other healthcare professionals who have worked closely with the applicant. These references provide insights into the applicant’s clinical competence, professionalism, and interpersonal skills.
  5. Background checks. Background checks are conducted to identify any criminal records, sanctions, or exclusions from federal healthcare programs. This step helps ensure patient safety and the integrity of the healthcare system.
  6. Committee review and decision. The organization reviews all the gathered information and makes a decision regarding the applicant’s credentials. This decision could include granting credentialing, requesting additional information, placing conditions or limitations on the provider’s practice, or denying the application.
  7. Ongoing monitoring. Once credentialed, healthcare providers may be subject to ongoing monitoring and reevaluation to maintain their credentials. This may include periodic license verifications, continuous professional development requirements, performance evaluations, and peer reviews.

It’s important to note that the specific credentialing process can vary depending on state regulations and the type of healthcare facility. The timeline for credentialing can also vary — ranging from a few weeks to several months — depending on the complexity of the application and the organization’s processes.

How To Choose Healthcare Credentialing Software

Only about a third of healthcare organizations use digital credentialing, which can pose significant compliance problems — not to mention delays and revenue loss! Switching to a digital, cloud-based credentialing system can speed up the process and open the door for opportunities to more organized credentialing and improved continuity when there are staff changes.

Here’s a look at how to make the switch to digital credentialing software the right way:

  • Bring together stakeholders. Every member of your organization that has a vested interest or role in choosing software should be accounted for. This might include your compliance team, leadership, IT, and legal, among others. 
  • Assess your needs. Not every piece of software will be the perfect fit. Identify the hardest parts of your current process and prioritize those when looking at credentialing software and the features offered.
  • Identify potential features. Make a list of all features available, and then rank them based on their importance in your decision. Consider features like centralized document storage, cloud-based functionality, CAQH provider profile management, configurable workflows, automated reminders, electronic forms and signatures, and real-time reporting.
  • Conduct research. Look into all the different credentialing software providers and identify the ones with features and benefits that you ranked highly. Evaluate the software based on its reputability in the industry. 
  • Request demos. It’s important to see credentialing software in action before you choose to invest in it. Schedule a demo, ask questions, and make sure you have a clear understanding of how it works and what to expect.  
  • Evaluate your options. Take a look at the contenders that check all your boxes and identify the one that’ll match your needs the best, while also offering the best value. Keep long-term scalability and growth in mind. 

After following these steps, all that’s left to do is pull the trigger on healthcare credentialing software that enables better compliance for your organization and its clinicians!

MedTrainer Simplifies Medical Credentialing

Making the leap from pen and paper credentialing to a robust cloud-based platform can be intimidating. That’s why MedTrainer puts an emphasis on making the process as simple, easy, and reassuring as possible for organizations looking to improve their credentialing processes. 

If you’re looking for medical credentialing software, find out why MedTrainer should be on your list!