Credentialing Process for Physicians in the Healthcare Industry

Credentialing in the medical industry is the process of verifying the provided records that allow doctors to begin practicing. This would include hospital admitting privileges, malpractice insurance, educational certificates, work history, references, and other information. It is a critical medical process that is required to maintain patient health safety standards.

A doctorate degree may not be enough for someone who wishes to work in the medical healthcare field. Regardless of whether you have certifications and meet all of the requirements for your first job at a hospital or starting your own practice, you will need to show the credentialing details in order to be paid for the services rendered. You must do your practice credentials through the best medical credentialing companies. If you have recently completed your medical studies, you may be wondering what the credentialing process for physicians entails.

What is the physician credentialing procedure?

Doctors and other parties who verify the required information are involved in healthcare provider credentialing or physician credentialing. Simultaneously, health organizations work to analyze the work of medical providers in order to evaluate reports that may be involved in malpractice or other means.
All of these reports are closely monitored by healthcare facilities as well as insurance companies, which provide a list of approved healthcare practitioners for reimbursement. The credentialing process, which is required for healthcare providers and nurses, can be less extensive at times.
There are several types of medical credentialing for physicians, some of which are;

• Insurance certification;

When a health insurance company verifies a provider’s credentials, the term “getting on the insurance panel” is used. Insurance credentialing occurs whenever an insurance company adds a provider to its in-network provider list.

• Credentialing without paper;

The credentialing process is carried out using software, which speeds up the process and eliminates the need for documents and papers to be verified. In other words, the software directly verifies the documents provided by the issuers.

• Medical sales rep credentialing;

Also known as vendor credentialing,’ this procedure is used when healthcare organizations need to verify the training and background of vendors and sales reps before allowing them to enter a medical facility.

Documents and information needed for physician credentialing

These are some of the details that you must provide as a healthcare provider, depending on the requirements of your state, healthcare facility, and insurance provider.

  • Name
  • Previous/other names
  • Gender
  • Ethnicity
  • Mailing address
  • Email address
  • Daytime phone number
  • Citizenship information
  • Recent photograph
  • Current CV
  • Date of birth
  • Social Security number
  • Education and training
  • Residency
  • Licensing
  • Specialties
  • Specialty certificates
  • Qualifications
  • Career history
  • Patient age focus
  • Languages spoken
  • Hospital affiliations
  • Medical group affiliation
  • Practice address
  • Practice Tax ID Number
  • Practice phone number
  • Primary practice contact
  • National Provider Identifier (NPI) number
  • Board certification
  • Acceptance of new patients
  • Sanctions or disciplinary actions
  • Malpractice claims history
  • Proof of professional liability insurance
  • Continuing medical education documents
  • Peer references

Medical credentialing standards

The standards for physician credentialing are set by the Joint Commission on Accreditation of Healthcare Organizations and the federal Centers for Medicare & Medicaid Services (CMS). Especially hospitals and practices that do not follow CMS standards and guidelines are not eligible for Medicare or Medicaid reimbursement. Similarly, the Joint Commission on Accreditation of Healthcare Organizations only recognizes hospitals and facilities that adhere to their guidelines. Although states regulate their own tailored regulations, many hospital facilities adhere to Joint Commission on Accreditation regulations in order to be accepted by CMS.

Furthermore, in order to increase accreditation, healthcare organizations adhere to credentialing guidelines established by other organizations. Among these groups are:

  • Utilization Review Accreditation Commission (URAC)
  • The National Committee for Quality Assurance (NCQA)
  • Det Norske Veritas (DNV)
  • The Accreditation Association for Ambulatory Healthcare (AAAHC)

The credentialing process for physicians consists primarily of three steps, which are as follows:

1. Gathering information

The health insurance company or healthcare facility requests information from physicians such as background, educational certificates, licenses, and so on. The physician may also submit the necessary documents via email, a questionnaire, or software.

2. Check the information

Healthcare facilities frequently collaborate with corresponding agencies such as medical billing service providers to verify information, such as licensing agencies, certification or training institutes, medical schools, and so on.

When using physician credentialing software, insurance companies or facilities check the provided information on a regular basis through entities and agencies that provide their information online for background checks.

Third-party credentialing services also collaborate with healthcare facilities to verify data. With the updated software, they aid in credentialing by checking licenses, expiration dates, and malpractice information available online, and re-checking if necessary.

3. Providing credentials to physicians

At last, after the background check is completed and no negative issues are discovered, the physician is granted working credentials. Insurance companies, if pleased with the outcome, will approve the physician for reimbursement through the in-network provider list.

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