Every patient deserves to be attended to by the right healthcare professional, get the correct investigations, diagnosis, interventions, and ultimately achieve the optimal outcome. Credentialing and privileging in healthcare are two critical processes that give healthcare organizations the power to do exactly that, ensuring their patients are safe and properly attended to.
Understanding Credentialing and Privileging
Credentialing is the process of verifying that healthcare providers have the required education, professional certification, licensing, and prior experience to administer patient care. It confirms that a healthcare worker is eligible to practice.
Privileging is the process of authorizing a healthcare worker to carry out specific procedures on patients following an assessment of their training, competence, and experience in that particular area.
Credentialing and privileging are both required before healthcare workers can attend to patients. Carrying out these processes thoroughly is important to:
- Ensure patient safety by hiring only competent healthcare workers
- Maintain a high quality of care
- Reduce the risk of malpractice claims
- Ensure compliance with regulatory standards and avoid credentialing issues
Credentialing vs. Privileging: Key Differences
Credentialing and privileging in healthcare are similar but not the same. They are both important for the smooth running of any healthcare organization, but a lack of understanding of the difference between the two can lead to serious compliance and patient safety issues.
Purpose and Scope
Credentialing verifies a healthcare worker’s general qualifications and expertise, while privileging confirms that a healthcare worker has the specific competencies required to carry out particular procedures and interventions.
Credentialing is a broader process that is done for all healthcare workers applying to work in a healthcare organization.
Privileging is more specific. It determines what specific procedures a particular healthcare worker is allowed to perform in a specific healthcare organization.
Timing and Process
Credentialing is typically done during the hiring process, while privileging is usually done at the start of employment and depends on the healthcare worker’s role and the procedures they are qualified to perform.
Regulatory and Accrediting Body Standards
Different regulatory bodies have different standards for credentialing and privileging, including the process, what is required, and the timeline for renewal.
The Joint Commission regulates hospitals and ensures the competence of the healthcare worker and patient safety. Primary Source Verification (PSV) is required. Privileging is authorized by the executive board of the organization and must be renewed every two years. Once privileging is completed, the healthcare provider’s performance needs to be monitored using the Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE).
The National Committee for Quality Assurance (NCQA) focuses on quality assurance at healthcare practitioner networks. Credentialing accreditation is handled by a credentialing committee for organizations that carry out complete credentialing. This committee renews the process every three years. It requires state license verification, board certification, education, sanctions check, work, and malpractice history. The NCQA does not require privileging.
The Centers for Medicare and Medicaid Services (CMS) are involved in regulatory compliance, reimbursement, and safety at Medicare and Medicaid-authorized providers. CMS requires healthcare workers providing care under Medicare and Medicaid to meet all state and federal credentialing requirements, including licensure and qualifications. Privileging is authorized by the hospital’s executive board and is carried out according to generally accepted standards. Specific privileging standards under CMS are done according to the Joint Commission’s standards.
How They Work Together in Provider Lifecycle Management
While we’ve seen the difference between credentialing and privileging, we must also understand that they’re both vital in managing providers over the course of their life cycle in a healthcare organization.
They both work together in a lock and key model to ensure holistic and effective healthcare operations and provider data management.
Credentialing involves verifying education, training, and certifications of the provider. Privileging confirms providers’ ability to perform specific interventions and permits them to do so.
As such, credentialing providers without privileging hinders them from deploying their full expertise to deliver maximum care to patients.
Also, as providers transition through different stages of their careers such as taking on new roles or relocating to another facility, credentialing ensures their records remain up to date, while privileging is re-evaluated to reflect any changes in their scope of practice.
This coordinated effort helps healthcare organizations enhance patient safety and supports efficient provider lifecycle management.
Medical staff services teams typically manage not just credentialing and privileging, but also enrollment, onboarding, and ongoing evaluation. These roles are complex, requiring a lot of documentation and communication, interrelated, and leave little room for error.
To keep up with the demanding nature of the job, medical staff services professionals must be extremely organized or enlist hospital credentialing software services to stay on top of their numerous, often complicated tasks. They must also be proactive with communication and following up with agencies, healthcare workers, payers, and members of the executive board.
Technology’s Role in Managing Both Processes
Credentialing and privileging are time-consuming processes with many moving parts. When done manually, the process can be difficult and prone to many errors. These days, technology has given us the tools to automate these processes, making them simpler and shorter.
The typical credentialing process for a health system takes 120 to 180 days. This is a long time for a healthcare worker to wait to start caring for patients. Modern credentialing platforms support documentation and tracking by:
- Simplifying data requests from providers during the credentialing process
- Handling regulatory requirements for healthcare providers
- Continuous monitoring to track and send alerts of expiration and renewal dates.
The end of credentialing does not have to signal the beginning of another manual, tasking process. With the data available on modern cloud-based data providers, privileging can be done automatically, matching the healthcare worker’s credentials to their appropriate privileges. Monitoring of these privileges is also done automatically.
Clarifying Credentialing and Privileging
Credentialing and privileging in healthcare are two different processes that are required for healthcare providers to care for patients. Credentialing confirms that a healthcare provider is licensed to practice. Privileging authorises a healthcare provider to perform specific procedures based on their training and experience.
Privileging depends on credentialing to be accurate and cannot be done until credentialing is complete.
It is important to be clear on the difference between the two to avoid mistaking one for the other. Such mistakes are costly for the organization and could result in compromised patient safety, poor quality of care, loss of public trust, malpractice claims, and loss of revenue.
Verisys can help you do the grunt work of credentialing and privileging in a much shorter amount of time. With a large provider dataset, real-time primary source verification, and a team of credentialing experts, you can stay focused on providing care to patients while your credentialing and privileging needs are duly handled.
Sources:
National Library of Medicine, Credentialing
https://www.ncbi.nlm.nih.gov/books/NBK519504/
The Joint Commission, key elements needed to meet the (OPPE) requirements
The National Committee for Quality Assurance (NCQA), Credentialing Accreditation Requirements
https://www.ncqa.org/programs/health-plans/credentialing/benefits-support/standards/
The National Association Medical Staff Services, Credentialing Standards
https://www.namss.org/Portals/0/NAMSS_1260700-23_ICS_Document_UpdateFINAL%20%281%29.pdf
