Hospital credentialing, sometimes referred to as healthcare credentialing, is the process of verifying that a provider is qualified to provide medical services. Although credentialing can be expensive and time-consuming, it is legally required and ensures quality and safety for patients. Done properly, hospital credentialing also protects providers and hospitals.
Though credentialing and privileging are often used interchangeably, they are distinct processes. Credentialing, which happens first, verifies the information and qualifications of a provider. After credentialing, privileges are granted, authorizing the provider to practice medicine at a specific healthcare facility.
Before physicians can provide services, their credentials must be verified to ensure they meet legal and professional requirements. During the hospital credentialing process, the medical staff requests details about a provider’s education, certifications, licensure, work experience, insurance, and background. They then verify that the documentation is accurate, genuine, current, and in good standing, ensuring compliance with all credentialing requirements.
How Does the Hospital Credentialing Process Work?
In 1951, the Joint Commission was formed to formalize hospital quality standards. Since then, the Commission has required hospitals to establish credentialing committees that oversee physicians’ competence and conduct regular reviews.
Each healthcare facility may use its own methods to collect and verify information, but they must adhere to the same documentation requirements. Once a provider’s application is submitted, the medical staff begins requesting documentation and verifying it through primary sources.
Key credentialing documentation includes:
- State license
- Board qualification/certification status
- Surgical logs
- Documentation of hospital privileges
- 10-year insurance claims report
- Updated curriculum vitae
- ACLS/BLS certification
- DEA certificate
- Immunization records
- School diploma
- Professional reference(s)
- Residency diploma
- Driver’s license
- Social Security card
The verification process often involves background checks and sanction checks with the Office of Inspector General (OIG). Once verified, the application is reviewed by an executive committee, which may meet with the applicant before approving their credentials.
Types of Hospital Privileging
After receiving approval for a physician’s hospital credentials, the health system may grant specific privileges for practicing at the hospital. These include:
- Active or admitting privileges: Authorizes physicians to admit patients into the hospital.
- Courtesy privileges: Allows providers to admit or treat patients on a limited basis.
- Surgical privileges: Permits physicians to perform surgeries.
How is Telehealth Credentialing Different from Hospital Credentialing?
For telehealth practitioners and smaller healthcare facilities, the credentialing and privileging process can be disproportionately expensive. With fewer resources available to commit to the credentialing process, credentialing and privileging can create a barrier to telehealth patients receiving care.
This is especially true in emergency situations such as pandemics, where staffing and financial resources normally used for credentialing are diverted to the care of critically ill COVID-19 patients.
To speed up the credentialing process, telehealth practitioners may take advantage of “credentialing by proxy.” In this situation, a provider may be credentialed to practice at a distant site while being overseen by an associated originating site such as a hospital.
The Centers for Medicare and Medicaid Services (CMS) established credentialing by proxy as a way for telehealth practitioners to save time and money during the credentialing process. CMS has also waived certain requirements during the COVID-19 crisis. However, credentialing by proxy still requires oversight, and several key requirements must be met. These include:
- A written agreement must be signed by both parties (telehealth practitioners and healthcare facilities).
- The practitioner must provide a license to practice.
- The telehealth practitioner must have privileges at the distant site. Evidence of these privileges must be provided to the originating hospital.
- The distant site must be certified as a Medicare or telehealth facility.
- The originating hospital must review the telehealth practitioner’s performance and share this information with the distant site. They must also share any complaints or adverse events regarding the practitioner with the distant site.
When choosing credentialing by proxy, hospital risk managers can work with hospital staff to ensure all CMS regulations are met. In addition, state laws, hospital boards, accrediting bodies, insurance providers, and third-party payers may have additional requirements that telehealth practitioners must meet during the credentialing process.
3 Common Credentialing Roadblocks That Cause Delays
There are three major roadblocks that frequently cause credentialing delays. Stay aware of these issues to help speed up the credentialing process:
- Missing, outdated, or incomplete information on credentialing applications. The most frequently missing data are work history and current work status, malpractice insurance, hospital privileges, and attestations. When undergoing credentialing, your application should be thorough – small inaccuracies or incomplete information can slow the credentialing process. However, you can prevent delays by submitting your most current information to The Coalition for Affordable Quality Healthcare (CAQH).
- Different states have different regulations. Regulations vary by state; physicians should be aware of the regulations of each state in which they provide services. When physicians understand state regulations, they can stay in compliance and streamline the process. Several states have reciprocity regulations, meaning that if a physician is credentialed in one state by a payer, their credentialing in another state for that same payer may be streamlined.
- Organizations misunderstand credentialing responsibilities. Hospital credentialing and healthcare license verification can no longer be used for a physician’s practice. Each healthcare organization must conduct its own credentialing to accept patients’ insurance. Credentials verification organizations can help healthcare practitioners comply with the strict standards of Medicaid and Medicare.
Verisys is a Credentials Verification Organization
At Verisys, we provide end-to-end credentialing services, including primary source verification, continuous monitoring, and background checks. Our solutions ensure that healthcare facilities comply with credentialing requirements, helping to protect patients, streamline the credentialing process, and safeguard the reputation of your health system.
Credentialing help is available. With provider compliance solutions such as end-to-end provider credentialing, primary source verification, continuous monitoring, and background checks.
Verisys helps hospitals and healthcare organizations save time and money by streamlining credentialing and compliance. Our advanced technology simplifies healthcare credentialing, ensuring compliance and prioritizing patient safety. We accurately verify provider credentials and continuously monitor compliance, helping hospitals, clinics, pharmacies, telehealth providers, and more meet credentialing standards. Protect your patients and your organization with Verisys.
