What Is Credentialing In Healthcare

Credentialing in healthcare is a formal process that involves using a series of established guidelines to ensure that patients get the best healthcare from medical professionals who undergo strict scrutiny about their ability to offer healthcare services.

While the healthcare credentialing process is done by a credentialing organization, it’s initiated by the medical services provider. Healthcare organizations are responsible for getting the relevant information to the individual who oversees the entire credentialing process. In a healthcare organization, this is handled by a designated credentialing officer. This can be a medical staff supervisor or practice manager.

How Credentialing in Healthcare Works

When credentialing the personnel in your facility, you will verify whether they are legally considered licensed independent practitioners (LIPs). Thus, you must verify their training and education from primary sources.

This is a tedious process that involves a lot of documentation. Here is the most commonly requested information during healthcare credentialing:

  • Education and training – this includes information about the healthcare professional’s education and training, including degrees, certifications, and licenses.
  • Work history – the credentialing organization will check details about the healthcare professional’s work history, including previous positions, employers, and job responsibilities.
  • Licensure and certifications – this is the information about the healthcare professional’s current and previous medical licenses, board certifications, and any other certifications related to their field.
  • Malpractice history – any history of malpractice claims or disciplinary actions taken against the healthcare professional will also be checked.
  • References – involves verifying the contact information for individuals who can provide references for the healthcare professional, such as previous supervisors, colleagues, or patients.
  • Background checks – checking criminal background checks and other screenings to verify the healthcare professional’s identity and ensure that they have not been involved in any criminal activity or fraudulent behavior.
  • Skills assessment – evaluations of the healthcare professional’s clinical skills and competency, often through testing or observation.

The healthcare facility gathers this information about the practitioner and then checks it with the relevant medical boards, colleges, licensing agencies, and other institutions to verify it.

When the information is reviewed and verified, the healthcare facility will award the relevant credentials to the medical provider. These credentials indicate that the medical practitioner has all the necessary skills and ability to work in their assigned medical position.

Privileging and Payer Enrollment

In addition to the credentialing process, a healthcare provider can do privileging and payer enrollment. Most people tend to confuse these two processes and, at times, assume that once any of these steps are met, the practitioner is ready to work at the facility.

At their most basic level, these three processes are:

  • Credentialing – this is performing background checks. It’s also referred to as primary source verification.
  • Privileging – the process of ensuring that a medical practitioner processes all the appropriate experience and training that meet the minimum requirements, as well as the authorizations to perform requested procedures at the facility.
  • Payer enrollment – is the process of registering and enrolling with a healthcare payer, such as an insurance company or government program, to be able to bill and receive payment for healthcare services provided to patients covered by that payer.

With that said, let’s look at why healthcare credentialing is important.

Gives Patients Confidence

Healthcare credentialing instills confidence in patients by assuring that the healthcare professionals treating them have met strict standards of competence and qualifications. When patients know their healthcare providers have been through a rigorous credentialing process, they are more likely to trust them. They have confidence in their ability to provide high-quality care.

Credentialing helps to ensure that healthcare providers have the necessary education, training, and experience to provide safe and effective care. This can include verifying their medical education, board certifications, and licensure, as well as checking their work and malpractice histories.

When patients see that their healthcare providers have met these standards, it can help to build trust and confidence in the healthcare system as a whole. Patients are more likely to feel comfortable seeking medical care and complying with treatment recommendations when they know that their healthcare providers are highly qualified and competent.

Thus, healthcare credentialing plays a vital role in instilling patient confidence by ensuring that healthcare providers have the qualifications and experience to provide safe and effective care. This can help to improve patient outcomes and promote trust in the healthcare system.

Reduces Medical Errors

Healthcare credentialing, which is part of CVO credentialing, is a thorough process that verifies healthcare professionals’ education, training, and experience to ensure they are qualified and competent enough to provide safe and effective care. This process plays a crucial role in reducing medical errors in several ways:

  • Identification of unqualified providers – healthcare credentialing ensures that only qualified healthcare providers are authorized to practice medicine, minimizing the risk of medical errors that could result from untrained or inexperienced providers.
  • Adherence to best practices – credentialing organizations enforce evidence-based best practices among healthcare providers, guaranteeing that patients receive high-quality care based on current research and best practices. This, in turn, helps to decrease the incidence of medical errors.
  • Continuing education – healthcare credentialing organizations require providers to continually participate in education and training to maintain their credentials, keeping them up-to-date with the latest advancements and knowledge in their field. This reduces the risk of medical errors resulting from outdated practices or expertise.
  • Oversight and accountability – healthcare credentialing organizations have monitoring mechanisms to ensure healthcare providers follow established guidelines and best practices. This promotes oversight and accountability among healthcare providers, decreasing the risk of medical errors resulting from negligence or non-compliance.

Helps Lower Costs

When properly credentialed, healthcare providers can provide high-quality care that meets industry standards. This can result in better patient outcomes, which can help reduce the cost of healthcare in several ways.

When patients receive high-quality care, they’re less likely to need additional treatments or hospitalizations. This can help reduce healthcare costs by avoiding unnecessary expenses. Also, credentialing helps healthcare organizations identify providers with specialized skills and expertise. This can improve efficiency by ensuring patients are referred to the most appropriate provider for their needs. This can help reduce the cost of healthcare by avoiding unnecessary tests, procedures, and referrals.

Bottom Line

Although healthcare practitioners undergo annual training, it may be challenging to recognize the significance of healthcare credentialing. For physicians, most of the credentialing process involves submitting paperwork, which can be time-consuming and take attention away from treating patients. However, it is the cornerstone of today’s healthcare.

When a healthcare provider has their credentials in order, they have been confirmed as a doctor or nurse who has received proper training, been certified by an independent organization, and demonstrated the necessary expertise to deliver top-notch healthcare services. The healthcare industry lacks oversight and quality standards without rigorous physician credentialing. Therefore, credentialing is essential for ensuring high-quality healthcare services.