Credentialing

Credentialing is the process the healthcare facility or managed care organization/health plan uses to collect and verify the “credentials” of the applicant. This includes verification of many elements including licensure, education, training, experience, competency, and judgment.^[1]

Physicians and other healthcare providers who wish to provide care in a hospital, ambulatory care facility, or other healthcare facility must undergo an application process which includes verification of credentials. Additionally, providers that want to bill an insurance company and receive reimbursement for services as an in-network provider must undergo a process of credentialing. Healthcare facilities and health plans will verify relevant education including medical school, residency/fellowship training, board certification, licensure, professional liability insurance and claims history, and will query the National Practitioner Data Bank (NPDB). The NPDB is an electronic repository containing information on medical malpractice payments and certain adverse actions related to healthcare practitioners, entities, providers, and suppliers. Although the basic aspects of credentialing are performed in the same way, there are different credentials verified depending on the environment. For example, hospitals will typically request information concerning procedures performed in order to document that the applicant is meeting current competency requirements for privileges requested, but health plans (insurance companies) do not typically collect this information because health plans do not grant privileges. Since healthcare facilities grant clinical privileges, these organizations will also write to contact other facilities where a provider has worked and obtain professional references to verify experience, competency, and to determine whether any disciplinary actions were taken against the provider.^[2]

The approval process in a healthcare facility typically involves a review of the applicant's credentials and qualifications with recommendations for appointment and privileges made by the medical staff via a department chairperson, the credentials committee, and the medical executive committee. The approval process varies depending on the medical staff structure. The actual approval of privileges and appointment is made by the board of directors. Some healthcare facilities have a mandatory requirement for interviews, and some hospitals will only interview physicians under certain circumstances as defined in the medical staff's bylaws.

In a health plan, the credentialing process differs from that of a hospital. In a health plan, the provider enrolls in the provider panel network. After the application is submitted and credentials are verified, the approval process will involve review and approval by the network's medical director or credentialing committee.

Typically, insurance companies require credentialing for the following providers

• Physicians MDs, DOs
• Dentists
• Physical Therapists,
• Speech Therapists
• Psychology Counselors
• Occupational Therapists
• LMFT
• Group Medical Practices
• Clinics
• Hospitals
• DME Companies
• Home health agencies

Provider credentialing is different from provider enrollment. Provider enrollment is the process of enrolling a provider with insurance payers. The provider must submit a credentialing application that details their training and qualifications to treat patients in their area of specialty. While hospitals and health systems typically have their own provider enrollment team to perform this function, independent group practices and solo practitioners may contract with another organization to perform this function.

The Centers for Medicare and Medicaid Services (CMS) Conditions of Participation (CoPs) allow an originating site facility to use proxy credentialing when telemedicine services are provided by a practitioner affiliated with and credentialed by either a Medicare-participating distant site hospital or an entity that qualifies as a distant site telemedicine entity; and when there is a written agreement that satisfies certain requirements that are enumerated in the regulations. This allows the parties to share information regarding credentialing decisions, as well as periodic updates of practitioner reviews and assessments. While healthcare accreditation organizations have largely aligned their standards with CMS regulations, each state has its own regulations regarding hospital licensure and many states’ regulations include regulations governing the structure and/or operation of the medical staff, including credentialing requirements.^[3]

A healthcare facility may choose to utilize credentialing by proxy under the CMS regulations for telemedicine providers, or it may utilize the process specified in the medical staff bylaws and policies and procedures for other medical staff appointees.

TJC (formerly known as JCAHO) was founded in 1951 and accredits and certifies healthcare organizations to meet quality standards. It envisions a future in which TJC is "leading the way to zero," which translates to zero harm in healthcare.

TJC, or the Joint Commission,^[4] accredits and certifies over 22,000 healthcare organizations and services in the United States. TJC accreditation establishes a baseline for patient safety and process improvement. Healthcare facilities which want to supply services to Medicare, Medicaid and other Federal healthcare plans may utilize Joint Commission accreditation in lieu of being surveyed by the State Health Department.

Credentialing ^[5] requires more comprehensive data of the professional, political member or a group of professionals. The process of credentialing includes verification of the information such as:

• Education and training
• Residency
• Licenses
• Specialty certificates
• Qualifications
• Career history

There are three types of Credentialing

• Personal Credentialing
• Political Credentialing
• Paperless Credentialing

Personnel credentialing is typically undertaken at commencement of employment (initial application) and at regular intervals thereafter (reappointment). Credentialing of vendors or other organizations may begin prior to the purchasing process and be repeated regularly.

Political parties credential delegates at their conventions. Credentialing is required for the UN representatives in the General Assembly. A Credentials Committee^[6] consisting of nine members is appointed at the beginning of each regular session of the General Assembly. The Committee reports to the Assembly on the credentials of representatives.

Paperless credentialing is the process of doing credentialing through a software package. With the internet, many web-based programs have been created to help automate the process of paperless credentialing.

Some of Credentials verification Organizations in healthcare industry are as follows

• National Practitioner Data Bank
• The American Board of Medical Specialties
• American Association of Nurse Practitioners (AANP)/American Nurses Credentialing Center (ANCC)
• The Office of Inspector General (OIG) and the System for Award Management (SAM)
• Medical Board of Each US state

• Medical credentials
• Economic credentialing
• Actuarial credentialing and exams
• License
• Certification
• National Association Staff Services