Beginner's Guide to Healthcare Provider Credentialing

Credentialing is a time-consuming task that verifies a healthcare provider’s qualifications, certifications, experience, and training so they can practice. The application is detailed, and the requirements change frequently. If even the tiniest human error occurs, it can result in delays and setbacks for everyone involved. Credentialing is also not a one-time process — professionals must undergo re-credentialing every two to three years.

This beginner’s guide provides the fundamental knowledge required to understand this process, including the challenges and obstacles a professional might encounter. Partner with us at DoctorsManagement, LLC, to avoid possible pitfalls of credentialing in healthcare.

What Is Provider Credentialing?

Credentialing is vital in the healthcare industry. It involves vetting and evaluating health providers’ qualifications, backgrounds, and professional histories.

Provider credentialing is also a crucial protective measure for patients. Verifying health professionals’ knowledge, training, and references ensures patients receive care from providers with the necessary skills and experience to deliver safe, high-quality services. Credentials are significant in maintaining healthcare system integrity and promoting patient safety.

Credentialing ensures health providers like doctors and nurses have the appropriate qualifications to deliver safe and effective care. The process involves an exhaustive, systematic evaluation of the professional’s background. Credentialing involves verifying:

  • Education and training
  • Work experience
  • Certifications
  • Valid medical licenses and board certification
  • Malpractice history

Professionals undergo this process to prove they are competent and capable of providing a high level of care. Credentialing also maintains the integrity of healthcare institutions. Patients want to feel safe in hospitals and other facilities, and part of that is having staff they can trust.

Who Sets the Standards for Provider Credentialing?

Several entities define and enforce the credentialing criteria and processes, including government agencies, accreditation bodies, professional associations and boards, and insurance companies. For example, the Centers for Medicare and Medicaid provide credentials at the federal level.

There is also credentialing accreditation with the National Committee for Quality Assurance. NCQA Credentials Verification Organization Certification aims to improve the verification process by ensuring it is consistently effective. Their standards help identify improvement gaps and align their services with those desired by the contracting healthcare organizations.

Other specific credentials and accreditations exist for specialists like audiologists, dermatologists, and nurses. Meanwhile, CAQH is a tool for clients to eliminate redundant paperwork. They collaborate with health care plans, providers, and related organizations, streamlining communications and connections.

Challenges of Provider Credentialing

The provider credentialing process can sometimes take months due to the background checks, verification, and other requirements involved. New healthcare professionals earning credentials for the first time must wait before they can begin seeing patients, which could impact their income.

New Healthcare Professionals Earning Credentials

Other obstacles include the following.

  • Complexity and variability of requirements: The credentialing process in healthcare can be complex. A few organizations have compiled books to help first-timers, demonstrating how extensive the rules and regulations are. Requirements also vary between states and healthcare institutions. Not all ask for the same qualifications, and some might request uncommon items.
  • Risk of human error: While many applications are digital, some are still paper forms that health providers must fill out manually. These are often lengthy and can be prone to inaccuracies. Occasionally, these errors can have severe implications, including legal liabilities. Therefore, credentialing requires the utmost care and attention.
  • Managing re-credentialing: Novices can get overwhelmed by all the details and intricacies. However, re-credentialing is not a breeze either — complications include ongoing compliance and keeping track of all expiration dates.

Steps Required for Credentialing

Every credentialing organization will ask for different information, but some steps are broadly applicable.

  • Gather information: The first step is to collect details about your educational background, work history, and professional references. You will also need official documents like medical diplomas, certificates, state licenses, and malpractice insurance policies. Primary source verification is a critical aspect of the credentialing process. It involves obtaining information directly from original sources like licensing boards and educational institutions to confirm things like licenses, certifications, and degrees.
  • Background checks: Background checks are another critical component of the credentialing process. These involve assessing a provider’s criminal history, malpractice claims, disciplinary actions, and any other relevant information that may impact the ability to provide safe and ethical care.
  • Peer review: Some credentialing processes also include a peer review component. In this step, a committee of your peers will assess your clinical competence and professional conduct to ensure you meet the required standards of clinical practice and ethical behavior.
  • Double-check for accuracy: Review the application forms with a fine-toothed comb once you complete them. You may also want to ask a friend or family member to check that you’ve dotted all your I’s and crossed all your T’s. Everything must be correct to get it right on the first try and avoid delays.
  • Review and decision: A credentialing committee will start the review process after you submit your completed application and documentation. The panel will evaluate your qualifications, experience, and compliance with organizational or regulatory standards. This assessment can take 90 days, depending on the entity. If approved, you will have the privilege to practice or become eligible for participation in insurance networks.
  • Ongoing monitoring: Health provider credentialing is a continuing process, requiring providers to renew their credentials to maintain their eligibility to practice. Re-certification ensures you continue to meet the necessary standards and stay abreast of changes in your field. When you have earned your credentials, create a process to ensure everything is ready when it’s time to re-certify. Set reminders of expiration dates on your calendar. Document all the collected data and decision-making processes for future reference and compliance purposes.

Partner With Credentialing Experts

Partner With Credentialing Experts

Healthcare credentialing requirements can be intricate and complex, but you can streamline the process by partnering with DoctorsManagement, LLC. You only need to complete an onboarding application, but our team will help you expertly meet all the various credentialing requests and tasks. We have an in-depth understanding of the process and can advise you on timelines and tips to make it smoother.

Receive a custom quote from us with payment options that work for you. We facilitate credentialing and enrollment, letting you focus on what matters most — caring for patients and building your business. We will keep you abreast of your progress with transparent communication, so you can rest assured the process continues moving.

Request a free quote via phone at 800-635-4040 or reach out online.

Call Us (800) 635-4040