What Is Medical Credentialing? Significance & Types Of Credentialing

Congratulations! You got the job! But before you can go to work as the newest member of the team, you will have to complete the physician credentialing process. This may include:

Credentialing with the office, agency, or group that’s employing you Hospital privileging at the location(s) where you’ll be working Although these are different processes, they are often all lumped under the broader category of credentialing, because they share many of the same steps and elements. Whether you’ve accepted a permanent job or are exploring temporary locum tenens opportunities, here’s everything you need to know about how physician credentialing works.

What is physician credentialing?

Credentialing is a process that ensures a doctor is qualified to perform the procedures he or she was hired to perform. It helps protect both the physician and the facility from liability if the physician is charged with negligence or malpractice. Whether you have accepted a permanent position or are taking a weekend locum tenens assignment, you will still be required to complete the credentialing process. Credentialing can also include enrolling you with insurance providers so the facility can bill them for the services you provide to patients.

How is credentialing different from hospital privileging?

While the terms are sometimes used interchangeably, credentialing generally refers to ensuring physicians have the proper credentials to work for a health system or at a clinic or private practice. Hospital privileging refers to securing authorization for a physician to work in a specific capacity at a specific facility. Depending on your job, you may have to be credentialed for the health system and receive privileges at multiple facilities.

What is the typical timeframe for physician credentialing?

Because every facility is different, there is no standard timeframe for the credentialing process. Some facilities finish credentialing and privileging within a couple of weeks, while others may take up to six months. It depends on the organization’s accreditation, requirements, and bylaws.

If you’re taking a locum tenens assignment, ask your CompHealth hospital privileging coordinator about the typical timing for the facility where you’ll be working. They can give you a general overview of the credentialing process for that healthcare organization and provide an expected timeframe.

What Is The Significance Of Medical Credentialing?

Before we start discussing the steps, let’s answer the question of why is credentialing important in healthcare to get on the same page about the importance of healthcare credentialing, also known as insurance credentialing or medical credentialing.

Most facilities need to ensure their healthcare providers have proper credentials in order to process insurance claims. Even if some of your clients are uninsured or pay out-of-pocket, credentialing is important for providing broad access to care.

There are unique physician credentialing processes for different healthcare providers. While the process is vital for physicians, the provider credentialing process is also important for:

• Hospitals and health agencies
• Dentists
• Physical therapists
• Licensed massage therapists
• Counselors and psychologists

To accept Medicare and Medicaid, you’ll need to ensure your credentialing department meets guidelines from the following federal agencies:

Centers for Medicare & Medicaid Services (CMS)

The Joint Commission on Accreditation of Healthcare Organizations

Beyond these federal regulations, each state has its own healthcare credentialing requirements. Understanding and closely following these requirements can help reduce your practice’s liability in the face of potential malpractice claims.

Yet, as we noted, credentialing is time-consuming and even tedious. To make sure your healthcare providers receive proper credentials in a timely manner, follow these steps.

What Is The Complete Process of Medical Credentialing? ( A Step-by-Step Guide)

1. Identify the Required Documents

As you begin the provider credentialing process, be aware that each insurance company requires different documentation and forms. You’ll need to submit complete applications to each insurance company you plan to work with—and even a single missing piece of information can delay approval by weeks or months.

To ensure your applications are complete, make a list of all insurance companies you plan to file with. Then, list out any and all required documents. These often include but are not limited to:1

• Name
• Social security number
• Demographic information (ethnicity, gender, citizenship, languages spoken)
• Education and residency information
• Proof of licensure
• Career history
• Specialties and patient focus
• Claim history
• Proof of insurance
• Information about your healthcare facility

Hopefully, much of that information was reported in your healthcare provider’s resume and application. However, you’ll need to take steps to ensure its accuracy.

2. Prioritize Insurance Companies

Because you’ll need to submit multiple applications, it may be advantageous to prioritize which dossiers you submit first. If a significant portion of your medical billing goes through a single insurer, complete their credentialing application first.

Stay familiar with individual insurers’ regulations. Some health insurance companies—for example, Aetna—allow a streamlined process for providers who are already insured in another state.2 That may mean quicker approvals.

Other insurance providers offer an abbreviated application for providers who are already credentialed in-state. Make a list of your priorities and begin to assemble documents and applications accordingly.

3. Check for Accurate Information

As you begin to assemble required documents and begin individual applications, keep in mind that the quality and accuracy of information is key. Before submitting any application for provider credentialing, take the following steps:

Conduct a background check

Verify educational history, licensing, board certification, peer references, clinical priviledges, and reputation through healthcare organizations such as the American Medical Association (AMA), the Educational Commission for Foreign Medical Graduates Certification (ECFMG), and the American Board of Medical Specialties

Review the history of credentialing, privileges, and insurance claims List any sanctions recorded with the Office of Inspector General (OIG) Any errors in the submitted information can cause issues. For example:

• If months and dates of employment are not easily and accurately verified by past employers, revising the application with the correct information can delay the approval process.
• Likewise, incorrect phone numbers for references or past employers can create delays or even rejections.
• Omissions of past malpractice claims could be disqualifying.

Once you’ve assembled and verified these documents for your medical providers, you’re ready to present them to facility leadership who will determine the specific privileges to grant to the new provider. This information is vital for the credentialing process.

Manual Verification vs. Other Methods

Should your facility manually verify credentialing data or use an alternate method? Some healthcare facilities choose to undergo the credentialing process the old-fashioned way, calling and emailing medical schools, the American Medical Association, and other key organizations to verify the board certification and other information on a provider’s resume. However, this can be incredibly time-consuming, and any cut corners could result in further delays.

Other options include:

Credentialing software – Programs like Modio and Ready Doc automate parts of the credentialing process by cross-referencing resume and application information with AMA profiles, medical schools, the OIG, and more.

Outsourcing – Is your HR department overwhelmed with provider credentialing? Outsourcing and utilizing a credentialing service can potentially save precious time and money.

Once you’re sure you have accurate information, you can proceed to the next step.

4. Completing the CAQH

Several major healthcare insurers require partner facilities to apply for provider credentialing through the Council for Affordable Quality Healthcare (while also completing their individual applications).3 The process is as follows:

Once your facility has filed an application with an individual insurer, they’ll provide a CAQH number and an invitation to apply.

You’ll be given the option to complete the CAQH form on paper or online. Running to 50 pages when printed, this form is most efficiently completed on a computer (since the CAQH will have to manually enter the data on their end if it is provided on paper).

As with applications to individual insurers, CAQH approval can be significantly delayed by any inaccurate or incomplete information.

After submitting the initial application, be prepared to re-attest. What is re-attestation? To maintain continuous insurance eligibility, you’ll need to attest that a healthcare provider’s information is correct four times each year.

5. Wait for Verification

Once you’ve assembled and submitted your application to insurers, it’s time to wait for their approval. This can be a lengthy process.

While the credentialing process can be completed within 90 days, experts suggest giving yourself 150 days.4 If serious issues arise, credentialing can take even longer. Read more about credentialing issues in healthcare in the meantime.

6. Following Up

Don’t just wait five or six months to hear from an insurer. Credentialing healthcare professionals reveal that consistent follow-ups are key to timely approval. Here are a few best practices:

Cultivate relationships with key personnel at the insurance company. Establishing rapport with leadership, executive assistants, and other staff can help ensure that applications move along in a timely manner.
Check-in via phone rather than email to maximize the chance of a response.
If you find out that more information is required, compile and verify all documents in a timely manner.

7. Recertification

Eventually, your healthcare providers will receive their insurance panel credentialing. However, that doesn’t mean they’ll be credentialed forever. Unfortunately, healthcare provider credentialing is an ongoing process that requires more work down the line.

• If you discover an error in an employee’s information, it’s important to notify insurers. If they notice the erroneous information before you submit a formal correction, it could be grounds for revocation.
• Most providers need re-credentialing every three years.

As we’ve noted, credentialing software can help you manage credentialing. Likewise, it should notify you when it’s time to renew a specific provider’s credentials. However, insurers should also send a notification after three years have elapsed. Respond in a timely manner to ensure your provider can provide patient care without interruption.

What Are The 3 Types Of Medical Credentials?

An education- and work-related credential can be defined as a verification of an individual’s qualification or competence issued by a third party with the relevant authority to issue such credentials (U.S. Department of Labor, 2010). The term

credential encompasses educational certificates, degrees, certifications, and government-issued licenses.

Certificate

Certificates are awarded upon the successful completion of a brief course of study, usually one year or less but at times longer, primarily in public or private two-year institutions of higher education, university extension programs or nondegree granting postsecondary institutions like area career and technical education schools. Upon completion of a course of study, a certificate does not require any further action to retain.

Certification

Certifications indicate mastery of or competency in specific knowledge, skills or processes that can be measured against a set of accepted standards. These are not tied to a specific educational program, but are typically awarded through assessment and validation of skills in cooperation with a business, trade association or other industry group. After attaining a certification, individuals often must meet ongoing requirements to maintain the currency of the certification. 

License

A license is legal permission, typically granted by a government agency, to allow an individual to perform certain regulated tasks or occupations. A license can be obtained by meeting certain requirements set forth by the licenser, usually

by completing a course of education and/or assessments. Upon receipt of a license, ongoing requirements may be necessary to maintain the license.

Degree

An academic degree is an award or title conferred upon an individual for the completion of a program or courses of study over multiple years at postsecondary education institutions.