The Medical Credentialing Process
Do you research doctors prior to choosing one for yourself and your family? If you answered yes, then you know what it’s like to walk into your doctor’s office and realize that you’ll be seeing a new doctor in the practice for that day? Do you go for a quick Google search, or do you start to wonder; does this doctor know my condition? Is he/she as good as my original doctor? How long have they been licensed? Can I trust this doctor’s credentials? Let’s go ahead, and break down the credentialing process that a doctor must go through to work in a medical practice.
What Are the Requirements to Work In A Medical Practice?
Whenever physicians want new privileges or switch employers, it’s mandatory that they go through the credentialing process. In reference to fellows and residents completing their training, the credentialing process will be one of the first steps if they plan to work as a practicing physician.
In reference to healthcare, physician credentialing is the implementation of verifying and organizing the professional records required to qualify doctors to practice medicine, including:
Insurance
Education
Malpractice
Work history
Board certifications
Professional references
Medical credentialing is a critical safeguard for ensuring the safety of patients and for risk management. Organizations must obtain sourced verification of the clinician’s training, education, certifications, and licensure. They must also maintain a file on each provider.
This resource is intended as an introduction to medical credentialing to assist new graduates entering the healthcare industry. It can also offer a knowledge-base of basic credentialing terminology, as well as how the process works.
What Is Credentialing?
Credentialing is the first process you will go through when seeking employment in a medical facility. The employer needs to make sure that your credentials are valid and that you meet all the requirements to qualify as a staff member at their medical facility. This process will include the verification of:
Licenses
Residency
Qualifications
Career history
Specialty certificates
Education and training
This process is also known as primary source verification (PSV). As part of this process, the agency performing the credentialing will verify your information by contacting the initial source represented on your application.
Credentialing Process
Ultimately, the process starts with the provider, but the credentialing process itself is conducted by the credentialing organization. They’re the ones responsible for acquiring the necessary information for the person who’ll be administrating the process. Most healthcare organizations will have an assigned credentialing specialist.
Can the Credentialing Process Be Disrupted?
You can disrupt the completion of your credentialing process by supplying incorrect and incomplete information. This happens to be one of the major challenges in completing your medical credentialing process.
Many organizations utilize credentialing software to assist with the process of archiving information. This way, once the provider furnishes the information, it’s easy to access as often as needed for credentialing, payer enrollment, or privileging. Simply put, the credentialing specialist has a responsibility to keep the submitted information organized, streamlining the process, while the provider’s responsibility is to submit complete and accurate information.
Key Stakeholder Review
Once all the provider’s data has been received and verified, it will be sent over to the governing body and/or medical staff committee for review. The committee will generally include several members.
What Is Privileging and Payer Enrollment?
Besides credentialing, a provider will likely need to proceed with the privileging and payer enrollment process. The three basic levels of the process include:
Credentialing – Primary source credentialing or primary source verification (background check)
Privileging – Verification that the provider has received proper training and experience that meets all authorizations to handle procedures requested, and that the provider meets all the minimum requirements.
Payer Enrollment – This process is where the medical provider’s information gets entered into the network, Medicare, Medicaid, and insurance plans. Once this is completed, the facility and provider can start accepting payments for services rendered by the provider.
Background Checks
Background checks are one of the most crucial steps in the entire credentialing process. The three top background data banks used most frequently for healthcare background checks are:
Background checks will unveil any negative information or sanctions against the provider, and will also protect patients from inept medical practitioners.
Credentialing Tools
Credentialing can be time-consuming and prone to errors, as it is a manual process. Therefore, investing in credentialing software tools can be a great investment that can help to eliminate redundancy, reduce errors, and speed up the process of credentialing a provider. Credentialing software tools are also able to assist companies in ensuring that providers continue to stay compliant in order to resume practicing and being able to bill for services.
Conclusion
Medical Credentialing Software tools can offer your company more visibility, make it easier to monitor, and quickly identify potential risks that may forestall a provider’s start date. If you would like to learn more about the medical credentialing process and how it can benefit your healthcare facility, go ahead and fill out the form below. We look forward to hearing from you.
