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Medical Provider Credentialing 101

September 15, 2020

While medical credentialing might be considered a modern concept, credentialing dates as far back as the practice of medicine itself. The first documentation of credentialing can be traced to 1000 BC by the ancient Persian cult, Zoraster, in which physician licensure was outlined in The Vendidad, the book of the law.

The Venidad stated that in order to earn the right to practice medicine a candidate had to prove himself by successfully treating three heretics. If all three lived he was considered fit to practice medicine. If all three died, the candidate was denied the right to practice for the entirety of his or her lifetime. While the modern process of credentialing has changed substantially since then, the weight and importance of it have not.

What is Medical Provider Credentialing?

Modern medical credentialing requires more comprehensive provider data and exclusion screening rather than the treatment of three patients. Today, the National Practitioner Data Bank requires the thorough review of medical data including:

  • Education
  • Training
  • Residency
  • Licensing
  • Certificates
  • Qualifications
  • Career history

When starting a new practice or changing states, a medical professional must undergo the processes of credentialing and privileging including:

  • Provider credentialing: verifying and assessing education, training, licensing, qualifications, etc. which requires checking multiple databases.
  • Provider enrollment: requesting participation in a health insurance network
  • Provider privileging: authorizing and granting a licensed or certified healthcare practitioner’s specific scope of services

The credentialing process can take anywhere from 90 to 150 days, so it’s important to be prepared for multiple steps and paperwork. Failing to do so could delay healthcare practitioners’ ability to provide care, prevent eligibility for insurance reimbursements, and lead to litigation.

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How Provider Credentialing Differs from State to State 

Each state has varying credentialing laws and regulations. Providers should become familiar with the laws and regulations specific to the states in which they practice or will practice. Doing so will facilitate compliance so providers can begin the credentialing and privileging processes with confidence.

Each state runs its own licensing program and requires verification from a multitude of databases. Such essential information should be sourced from primary, verified sources. For example, the National Student Clearing House is the authority in regard to education history, allowing healthcare providers’ educations to be verified with accuracy.

The National Student Clearing House and hundreds of other verified databases are known as primary source verifications (PSV). They should be cross-referenced with each other to provide healthcare institutions a thorough view of a provider’s background and should include certifications, debarments and exclusions, security and sanctions, and malpractice lists. Third-party software can automate frequent updates and verify all state licenses for all taxonomies.

What is Provider Recredentialing? 

Recredentialing (also known as re-enrollment or revalidation) is a necessary part of verification for healthcare providers to continue providing services. Practitioners and facilities are typically recredentialed every three years, but state and healthcare plans vary and should be regularly checked for requirement updates. A provider will receive a notification at least sixty days prior to the recredentialing due date upon which they will need to complete their application for recredentialing.

The recredentialing process and necessary resources are almost identical to those required for the initial credentialing process. Necessary primary source verifications (PSV) include:

  • National Practitioner Number
  • State Medical License
  • DEA License
  • Board Certification
  • Sanctions and Exclusions
  • Malpractice
  • Disciplinary Information

If recredentialing is not completed within the deadline, the ability to provide healthcare services will be suspended until the process is completed. These delays could result in legal and financial penalties for the provider and healthcare organizations.

4 Steps to Streamline Provider Credentialing

In order to prevent delays and legal and financial issues, healthcare organizations can take steps to streamline the provider credentialing process.

  1. Begin credentialing as early as possible. The credentialing process can be time-intensive. Medical staff should begin the credentialing process four months before the provider’s expected start date.
  1. Provide medical staff and candidates with necessary resources. The credentialing process can be overwhelming. Provide your staff and candidates with as much information as possible to make their task easier and speed up the process… Some necessary resources include:
  1. Keep medical staff records up to date. By helping staff keep organized records of credentialing dates and paperwork, you can mitigate delays to your healthcare services. Because delays in the credentialing (or recredentialing process) could cause financial and legal risks to your institution, it is prudent to help your medical staff keep track of their records. A credentialing software system is the best way to automate the process and reduce administrative workload.
  1. Plan medical staff members’ start dates based upon credentialing. By linking a provider’s start date to the submission of their credentialing paperwork, your institution may avoid the need to schedule around insurance providers/payers with which the new staff member is not yet credentialed and reduce risk.

Verisys Streamlines the Medical Provider Credentialing Process

While medical provider credentialing can be time-consuming and difficult to navigate, it has proven to be a lasting process that will only become more complex over time. The essential process of medical credentialing is critical for healthcare organizations, physicians, and patients. Verisys streamlines the credentialing process for you helping your providers stay compliant, helping organizations improve patient trust, lowering the risk of medical errors, mitigating the risk of financial loss and penalties, and protecting your healthcare organization from potential litigation.

Utilize Verisys technology to automate your credentialing processes, license verifications, and continuous monitoring against primary and verified data sources, to ensure the highest quality of patient care and protection. As the gold standard in data screening, Verisys can help your healthcare organization navigate the complex medical provider credentialing or recredentialing processes.

Juliette Willard Written by Juliette Willard
Healthcare Communications Specialist
Being creative is my passion! Writer. Painter. Problem Solver. Optimist.
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