.png)
According to statistics, only six in ten Americans trust healthcare providers in the United States. If this skepticism towards medicine is not addressed, it will become challenging for healthcare providers to navigate the mistrust.
Patients need to feel confident that the providers caring for them are qualified and capable. So, how can this be addressed? This is where medical credentialing becomes important.
In this blog, we’ll discuss everything you need to know about medical credentialing. As you read, you’ll learn:
- The step-by-step medical credentialing process
- The timeline for completing a credentialing process
- Understanding the difference between credentialing and privileging
- Common challenges in medical credentialing
- How to maintain your credentials
- The impact of credentialing on healthcare providers
- Best practices for efficient credentialing
- How to streamline your credentialing process with Assured
Before getting into all of these, let’s first understand the basics of medical credentialing.
Understanding the Basics of Medical Credentialing
Think of medical credentialing as a bridge. Every single beam, bolt, and cable must be tested and verified to ensure the bridge will hold.
Medical provider credentialing is like that for healthcare. Without this “bridge,” there’s no way to guarantee that only qualified healthcare providers deliver care.
It’s like a background check but much more thorough. You wouldn’t trust an unlicensed pilot to fly a plane, and you wouldn’t want an uncredentialed doctor taking care of you, either.
What is the Purpose of Credentialing?
With credentialing, all practitioners provide a thorough review and verification of their education, training, work history, and professional licences.
According to research by the National Practitioner Data Bank, credentialing can help reduce the risk of malpractice claims. It does this by ensuring that providers have clean records and no history of disciplinary actions.
Who Needs to be Credentialed?
So, who needs to be credentialed? Certainly not just doctors. It’s a requirement for a wide range of healthcare providers, including:
- Physicians (MD/DO)
- Physician Assistant
- Nurses
- Social Workers
- Mental Health Counselors
- Dentists
- Psychologists
Anyone who provides direct care to patients needs to be credentialed. It is especially important for healthcare providers who want to work in hospitals, clinics, or insurance companies, as these organizations require proof of credentials before allowing providers to practice.
Key Stakeholders in the Credentialing Process
Several people are involved in the provider credentialing process.
First, we have the healthcare provider who needs to gather and submit all necessary documentation, including proof of education, training, and licensure.
Next, healthcare organizations, such as hospitals or clinics, review these credentials to ensure that the provider meets their standards.
Then, we have the credentialing specialists who help organize and verify the information. They act as the intermediaries between the provider and the healthcare organization, ensuring that all documentation is in order and the process runs smoothly.
Insurance companies also play a role, as they will not pay for services provided by unqualified individuals.
Finally, we have the regulatory bodies who oversee the entire process, ensuring that it adheres to state and federal guidelines.
The Step-by-Step Medical Credentialing Process
Now, to the most important question: How can the provider submit their credentials?
Well, keep reading to find out.
1. Application Submission
The credentialing process begins with the submission of an application. You’ll need to provide details about your education, training, work history, and licenses.
When submitting, you’ll also need to include documents like:
- Government-issued photo ID (e.g., driver's license or passport)
- Social Security card
- Current CV or resume
- Medical school diploma
- Residency and fellowship completion certificates
- Board certifications
- Current state medical license(s)
- DEA registration (if applicable)
- Malpractice insurance certificate
- Immunization records
- CPR or BLS certification
- Recent photograph (for identification purposes)
- Hospital affiliations and privileges letters
- Peer references (usually from the past 2-3 years)
- Continuing Medical Education (CME) certificates
- Any additional specialty certifications
Make sure everything is complete and accurate. Simple errors, such as missing information, outdated documents, or incorrect dates, can delay your applications. So, double-check your work history and include all required documents.
2. Primary Source Verification
After submitting your application, the next step is Primary Source Verification (PSV). This involves verifying the accuracy of the information the provider provided in your application.
Here, the credentialing specialists will contact the sources of your education, training, and licensure to confirm that the information is accurate.
For example, they may contact your medical school directly to verify that the provider graduated as claimed, or they may reach out to the licensing board to confirm that your license is current and in good standing.
They might also check your malpractice history and any disciplinary actions. This step ensures that all the information provided is true and accurate.
3. Committee Review
Once the information is verified, a credentialing committee reviews it. This committee is like a jury, deciding if you’re qualified to work in their organization.
They consist of experienced healthcare professionals who assess your qualifications and determine whether the provider meets the organization’s standards.
They evaluate your experience, professional behavior, and any history of disciplinary actions. The committee’s decision is based on whether the provider is capable of delivering safe, high-quality care to patients.
4. Final Determination and Notification
After the credentialing committee reviews your application, it makes a final determination.
If you meet all the necessary qualifications, you’ll be notified of the approval.
On the other hand, if the committee has any concerns, you’ll be notified and given an opportunity to address them.
Timeline of the Credentialing Process
The credentialing process takes around 60 to 90 days to complete, although this can vary depending on several factors, such as:
- The workload of the credentialing committee
- The completeness and accuracy of the application
- The speed at which primary sources respond to verification requests
Tips to Expedite the Process
The first thing to do is to ensure that your application is complete and accurate before submission.
This includes double-checking all information and including all necessary documents.
You should also respond promptly to any requests for additional information from credentialing specialists.
Following up with the primary sources of your credentials helps speed up the process.
Credentialing vs. Privileging: Understanding the Difference
It’s important to note that there is a big difference between credentialing and privileging.
Credentialing verifies your qualifications, but privileging allows the provider to perform specific procedures or services.
Think of it this way: Getting your driver’s license is credentialing, and then getting permission to drive a bus is privileging.
In simple terms, credentialing ensures qualification, and privileging determines what one is allowed to do.
For example, a surgeon may be credentialed to practice surgery, but based on their experience and expertise, they may only be privileged to perform certain types of surgeries.
Both credentialing and privileging work together. You need to be credentialed before the provider can be privileged.
Both are crucial for healthcare providers because without credentialing, there is no assurance that a provider is qualified to practice.
Without privileging, there is no assurance that the provider is performing procedures within their scope of expertise.
Together, both processes help maintain patient safety and trust in the healthcare system.
Common Challenges in Medical Credentialing
.png)
Let’s now explore some of the most common problems faced in medical credentialing.
1. Incomplete Applications
One of the most common challenges in the credentialing process is incomplete applications.
Missing information or documents can cause major delays, as credentialing specialists will need to follow up with the provider to obtain the necessary information.
To avoid this, the provider needs to take the time to carefully review your application before submitting it.
2. Delays in Verification
There are times when primary sources may take time to respond to verification requests, causing delays in the credentialing process.
To avoid this, the provider should follow up with these sources and encourage them to respond promptly.
3. Managing Multi-State Credentialing
For providers who practice in multiple states, managing credentialing requirements can be particularly challenging.
Each state has its credentialing requirements, and providers must ensure that they meet the standards in each state where they practice.
This can be a complex and time-consuming process, requiring careful organization and attention to detail. Using credentialing software can help providers manage multi-state credentialing by keeping track of each state’s requirements and deadlines.
4. Keeping Credentials Up-to-Date
Once a provider has been credentialed, they must keep their credentials up-to-date.
This includes renewing licenses, completing continuing education, and reporting any changes in credentials or status. Providers who fail to maintain their credentials risk losing their ability to practice or being removed from insurance panels.
The best way to prevent this from happening is to use a credentialing software.
The Role of Technology in Modern Credentialing
Thanks to technology, credentialing software can help providers keep track of their credentialing requirements and deadlines.
Platforms like Assured simplify the mountains of paperwork and countless verifications into a manageable system. They streamline the process, making it easier to submit applications, track verifications, and manage credentials.
With Assured, you can:
1. Collect Error-Free and Faster Provider
You can easily submit provider information. Choose to enter details directly or let us auto-populate from trusted sources like CAQH, NPPES, and state medical boards. This minimizes manual entry, reduces errors, and speeds up the process.
2. Automate Primary Source Verification (PSV) in Seconds
Say goodbye to manual checks with Assured’s automated PSV. We verify credentials such as education, licensure, board certifications, and employment history directly from primary sources with unmatched accuracy.
3. Perfectly Compliant CVO Applications
We ensure that every application adheres to credentialing standards and guidelines. Potential issues are flagged before submission so that you can be confident in complete compliance.
4. Scale Credentialing with Ease
Process multiple credentialing applications in parallel. This will eliminate the bottlenecks of sequential handling and enable your organization to scale quickly.
5. Real-Time Status Tracking
Stay in the loop with real-time tracking and dashboards that offer full visibility into each credentialing application's status. Receive instant alerts for any actions needed.
6. Intelligent Compliance Monitoring
Assured continuously monitors your providers' credentials. Receive automated alerts for expirations and renewals, ensuring compliance without gaps.
7. Streamlined Provider Roster Management
Generate rosters for both delegated entities and health plans within minutes. Our system consolidates multiple delegated rosters into one unified dataset/template, ensuring data consistency across all payer relationships and improving your administrative efficiency by 70%.
Maintaining Your Credentials: Ongoing Requirements
Credentialing isn’t a one-time event. Healthcare providers must undergo a credentialing process every two to three years.
During the credentialing process, the provider’s qualifications are reviewed again to ensure they continue to meet the required standards.
This process includes verifying ongoing education and updating any changes in the provider’s professional status.
1. Continuing Education Requirements
To maintain their credentials, providers must keep up with continuing education (CE) requirements.
Continuing education helps you stay up-to-date with the latest advancements and best practices.
Some healthcare providers are required to complete a certain number of CE hours within a specified period to renew their credentials. This ensures that providers remain knowledgeable and capable of delivering the best possible care.
2. Reporting Changes in Credentials or Status
If your credentials or professional status change, you need to report it right away. This includes updating your credentials if your status changes (such as disciplinary action) or if there are any significant changes in your professional history.
Failing to do so can lead to severe consequences, like losing your privileges or even your license.
The Impact of Credentialing on Healthcare Providers
There are various impacts of credentialing of healthcare providers. This includes financial implications, legal considerations, and effects on patient care.
Let’s take a look at some of these impacts.
1. Financial Implications of Delayed Credentialing
If you’re not credentialed, you can’t bill for services. This means lost income.
It can be particularly challenging if you’re starting a new role or opening a new practice.
According to research, credentialing delays can cost $9000 per provider per day. To avoid these unnecessary costs and delays, it’s important to start the process as early as possible and keep track of all required documentation.
2. Legal and Compliance Considerations
Credentialing is not just a matter of paperwork; it’s also about legal and compliance requirements.
Healthcare organizations must adhere to strict regulations to ensure that all providers are properly credentialed. Failure to comply with these regulations can lead to legal issues, fines, or even loss of accreditation.
3. Effect on Patient Care and Trust
Credentialing directly affects patient care. Patients need to trust that their providers are qualified and capable. Proper credentialing helps maintain that trust.
If patients find out that a provider is not properly credentialed, this can undermine their trust and potentially affect their willingness to seek care.
Best Practices for Efficient Credentialing
You can’t have a smooth credentialing process without preparation. Start by gathering all necessary documents and information. This includes educational records, training certificates, licenses, and any other relevant documentation.
Work closely with credentialing specialists to ensure that all your information is accurate and complete.
Building a good working relationship with credentialing specialists can help ensure a smoother and more efficient credentialing process.
Don’t forget to regularly review and update your documents to reflect any changes in your credentials or status.
Here’s an extra tip: Use credentialing software like Assured to store and manage all provider documents.
Streamlining Your Credentialing Process with Assured
With Assured, you get to save up to $50,000 annually per specialist. You get immediate access to specialized expertise and advanced tools without any additional investments.
With its user-friendly interface and automated features, Assured reduces the time and effort required for credentialing. It simplifies the entire process, allowing you to focus more on patient care and less on paperwork.
