Credentialing is a necessary process for health care professionals. And without it, it would be hard to maintain a high standard of patient care in the industry.
In many ways, improving this process will only benefit everyone involved. It ensures acceptable patient care, allows providers to build their credibility, and more. But what is credentialing exactly, and how does it affect patients and providers?
Keep reading to learn all about this essential quality assurance process.
- Credentialing is a process used to ensure health care providers have the necessary skills and qualifications to take care of patients.
- The documents required for credentialing vary per state but typically include an updated CV, National Provider Identifier (NPI), and board certification.
- Health care institutions have credentialing specialists on staff who can verify documents and check if providers meet standards set by the National Committee for Quality Assurance (NCQA).
- Medical credentials awarded include M.D., D.O., and C.N.P.; each with varying qualifications and educational requirements.
- Benefits of medical credentialing include patient trust, reimbursement, protection from lawsuits, and reduced instances of medical errors.
What Is Credentialing in Health Care?
Credentialing in health care refers to the process of verifying and evaluating the qualifications, education, training, licensure, and other credentials of health care providers, such as physicians, nurses, and allied health professionals, to ensure that they meet the standards required to practice in their respective fields.
When it comes to health care, we want to make sure that the people responsible for our well-being are up to snuff. That’s why there’s a whole process, such as credentialing, to check that health care providers have the necessary skills and knowledge to take care of us.
The National Committee for Quality Assurance (NCQA) is the organization that sets these high standards. Without going through this credentialing process, a health care provider can’t treat patients — it’s that important!
So, you could say that credentialing is one of the foundational elements that keep the health care industry running smoothly and safely.
How Credentialing Works
Credentialing is essentially a background check on a health care professional. With this, a provider should start compiling proof of their qualifications first.
Requirements for credentialing vary per state. But here are some of the common documents needed:
- Updated CV
- National Provider Identifier (NPI)
- Board certification
When it comes to getting credentialing, health care providers can breathe a little easier knowing that there are experts to help them out. Most health care institutions have credentialing specialists on staff, and these folks are pros at making sure all the necessary documents are in order.
So, if you’re a provider looking to get credentials, you can hand over your documents to the hospital and let the specialists do their thing. They’ll take the reins from there and start the verification process, which involves contacting various organizations.
Think medical boards, educational institutions, and more. The specialists leave no stone unturned in their quest to ensure providers are up to snuff.
And once everything checks out, the hospital is free to grant the provider their hard-earned credentials. It’s a team effort, and these specialists are an integral part of the process.
While this may vary between facilities, awards typically come in the form of:
- Identification cards
- Official letters
These awards don’t necessarily mean that a provider can practice medicine immediately. The health care facility still needs to define the services that a health care professional can provide. This is a process known as privileging, which you’ll get to know more about in this article.
Types of Medical Credentials
Most people are familiar with the term M.D., a credential used for doctors of medicine. But there is a much wider list of medical credentials in the industry that you should know of.
Indeed, knowledge is power when it comes to your health, so arm yourself with as much information as possible. You may accomplish this in part by checking the credentials of your service provider. These papers may provide you with a preview of their experience, education, and skills.
To help you out, below are some general examples of these that you may have seen before.
This certification is not just the most well-recognized in the industry, but also the most traditional. After studying and graduating from an accredited medical school, physicians earn a Doctor of Medicine degree. On top of that, they need to pass the Medical Licensing Exam (MLE).
A Doctor of Osteopathic Medicine is equivalent to an M.D. But a D.O. has a more holistic way of treating patients. A D.O. focuses on tackling the underlying cause of a disease. They take various factors into account, such as the musculoskeletal system and the mental and emotional health of a patient.
Certified Nurse Practitioners are all registered nurses (RN). But to be a C.N.P., one has to have advanced training and education in a certain field. For example, an R.N. must complete at least a master’s degree to become a C.N.P. With this added training, a C.N.P. can provide more personalized care for patients.
Why Medical Credentialing Is Important
As mentioned, medical credentialing exists to uphold an acceptable standard of care for patients. This includes the right treatment for their needs and ensuring their safety. But in reality, the importance of credentialing goes beyond that. It also serves to protect providers and their respective health care organizations too.
Below are more specific ways in which medical credentialing safeguards the interest of both parties.
Builds Trust With Patients
Put yourself in a patient’s shoes: Would you trust an unqualified doctor to treat you? Chances are, you wouldn’t.
Seeing a credentialed provider puts a patient at ease. Knowing that they’re in the hands of a well-equipped professional not only instills confidence in them but also trust.
Thus, this allows a patient to be more open and honest about their concerns and history. They’ll feel better about which procedures they’ve undergone or whether they’re following the doctor’s orders or not.
With this information, a health care provider can provide better, individualized care. And in the process, having fully credentialed professionals in your facility makes it more appealing to other patients and employees!
Necessary for Reimbursement
Medical facilities and health professionals earn money through partnerships with insurance companies. This includes Medicare and Medicaid, two of the U.S.A’s largest public health insurance programs.
These insurance companies require medical staff to have their credentials. Otherwise, payers may either delay or even refuse payments to uncredentialed providers.
Reduces Instances of Medical Errors
Medical malpractice is one of the leading causes of death in the country. Based on John Hopkins’ report, over 250,000 deaths occur yearly due to this.
This gives you a clearer picture of the importance of credentialing. By ensuring that health care providers know what they’re doing, medical credentialing can lower the risk of medical errors.
Protects You From Lawsuits
Keeping a detailed record of a medical staff’s credentials is essential in legal cases. Should there be malpractice claims on their services, this will help you tremendously.
Showing you have thoroughly checked a provider’s credentials protects you from liability. Thus, this will also save you from hefty fines related to the lawsuit.
The Medical Credentialing Process
The process of credentialing has three main parts. This includes credentialing, privileging, and enrollment.
As a whole, credentialing is a long and grueling task. But here’s a simplified overview of each stage of the process to help you out.
The first step of provider credentialing is making sure that providers are who they say they are. Providers must prepare documents that show their qualifications and credentials. This includes current licensure or board certification.
Afterward, an accredited entity, such as the Joint Commission on Accreditation, will verify these. These organizations will make use of primary source verification.
As such, they contact the document’s issuer to verify the information’s authenticity. You may learn all you need to know about a doctor’s background by searching their name in the National Practitioner Data Bank.
Once they find no issues with a provider’s accreditation, a health care facility awards a provider. This is a crucial step, as the facility not only gives you credentials, but also privileges.
During this stage, they will asses a provider’s qualifications and performance. This is so they can give a provider a clear set of patient care services they can do.
Several factors play a part in this decision-making. This includes the facility’s financial and equipment resources.
For example, a facility may take in a doctor who is licensed to carry out brain surgeries. But if the facility doesn’t have the equipment for this, this won’t be included in the doctor’s services. Now that you know more about this step, it’s evident that credentialing and privileging go hand in hand.
Privileging may lengthen the process. But it helps in avoiding contract disputes and legal actions.
This last step is optional. But a doctor can work with insurance companies as a way to bill for their patient care services.
Insurance companies only take in credentialed individuals. This isn’t limited to private health plans, but also to public ones such as Medicare and Medicaid.
Without enrollment, a health care professional can only see patients willing to pay upfront. So for providers, this may be a necessary step for them to practice medicine.
Frequently Asked Questions
What Is Meant by Professional Credentialing?
This is a way for institutions to authenticate an individual’s credentials and skills. It’s a lengthy process that follows a meticulous set of standards. This would need all relevant documentation from an employee. Verification organizations fact-check each one by reaching out to the primary issuer of each. Once done, the individual may be awarded credentials. This allows them to carry out tasks under the limitations of their privileges.
What Are the Advantages of Credentialing?
Credentialing has many advantages. It serves to benefit the patient, provider, and health care facility. It helps patients put their trust and confidence in their providers, for one. With a credentialed provider, they know they’re in good hands.
For providers, it allows them to earn money. They can partner with health plan companies to bill patients for their services. This also helps build and maintain a facility’s reputation. It’s appealing for many to have a team of credentialed providers. Not to mention, having qualified providers also helps in avoiding malpractice cases.
Does Credentialing Refer to a Certificate?
Credentials and certificates are often confused with one another. But these two don’t mean the same thing. In the health care industry, you need certificates to obtain the credentials. This is why the credentialing process asks for certificates.
You have to give these to prove your qualifications. Once you pass this, you’ll be awarded credentials by a health care facility. Some documents to prove your credentials include a certificate too!
So, what is credentialing? Ultimately, medical credentialing is the foundation of quality health care since it guarantees that only professionals with the necessary training and experience attend to patients. You may feel certain that your health care expert is up-to-date on the most recent procedures and practices in the medical field if you take the time to check their education, training, and license.
Indeed, medical credentialing will remain an important part of ensuring patient safety and fostering great care as the health care sector continues to develop. Understanding the relevance of medical credentialing and keeping up with the newest advances in this field is crucial whether you are a health care provider or a patient.
- “Provider Enrollment and Certification | CMS.” Www.cms.gov, www.cms.gov/Medicare/Provider-Enrollment-and-Certification.
- National Headache Foundation. “Key to Medical Credentials and Degrees.” National Headache Foundation, n.d., https://headaches.org/key-to-medical-credentials-and-degrees/.
- McMains, Vanessa. “Study Suggests Medical Errors Now Third Leading Cause of Death in the U.S. – 05/03/2016.” Hopkinsmedicine.org, 31 Dec. 2015, www.hopkinsmedicine.org/news/media/releases/study_suggests_medical_errors_now_third_leading_cause_of_death_in_the_us.
- The Joint Commission. “Medical Staff Standard MS.01.01.01: Primary Source Verification FAQs.” The Joint Commission, n.d., https://www.jointcommission.org/standards/standard-faqs/critical-access-hospital/medical-staff-ms/PrimarySourceVerification(PSV)
- “Standards – Credentialing.” NCQA, www.ncqa.org/programs/health-plans/credentialing/benefits-support/standards/.
- Importance of Medical Credentialing in Healthcare. www.caplinehealthcaremanagement.com/importance-of-medical-credentialing-in-healthcare/
- National Academies of Sciences, Engineering, and Medicine. “Credentialing and Privileging of Clinicians for Telehealth.” National Academies Press (US), 2020, https://www.ncbi.nlm.nih.gov/books/Credentialing.
- “CAQH – Streamlining the Business of Healthcare.” Www.caqh.org, www.caqh.org/about/newsletter/2021/why-provider-credentialing-necessary-hassle-and-vital-safeguard.