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The Credentialing and Privileging Process

August 20, 2020

Healthcare organizations are legally responsible for assuring that individuals providing patient care are credentialed, verified, and competent to do so. In order to guarantee compliance and quality patient care, the Centers for Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), and Health and Human Services (HHS) require that members of the medical and allied health staff are properly credentialed and privileged.

How does a physician become credentialed? Credentialing and privileging are both necessary before a physician is permitted to practice. The credentialing process verifies and assesses that a practitioner’s qualifications and license status are in good standing to provide healthcare services.

Alongside credentialing, privileging authorizes a licensed or certified healthcare practitioner’s specific scope of patient care services and evaluates an individual’s clinical qualifications and/or performance. Privileging ensures that medical staff is properly licensed, carry appropriate malpractice insurance, and meet hospital requirements.

Credentialing and privileging must both be completed before practitioners can provide patient care services. It is therefore critical that healthcare organizations have an efficient and thorough process of pre-application, application, identification, and processing to verify the providers’ credentials and grant privileges.

In order to provide a comprehensive primary source verification, healthcare organizations often hire a third party to verify credentials to ensure that the provider is screened against all state and federal exclusion lists, and their license is verified prior to hiring.

Credentialing for Telemedicine Providers 

Although they don’t maintain a physical presence in the hospital where they provide care, telehealth providers are still required by law to undergo updated credentialing. The telehealth industry is rapidly expanding; since the beginning of the COVID-19 pandemic, CMS has expanded payment for both telehealth services and credentialing which is also known as “credentialing by proxy.”

Credentialing by proxy permits the hospital to receive the telemedicine services (also known as the “originating site” hospital) and to rely on the privileging and credentialing decisions made by the hospital or entity that provides the telemedicine services (also known as the “distant site” hospital).

This streamlining allows hospitals to avoid the full administrative burden associated with the traditional credentialing process. It also reduces the redundancy and complexities of credentialing at multiple facilities allowing medical staff to provide services in more locations and hospitals and permitting rural hospitals to get the services they need.

This process allows hospitals and telemedicine providers to deliver services faster and at lower administrative overhead. However, if the proper monitoring tools are not in place, the lower barrier to entry could also expose hospitals to risk. Therefore, it’s critical to have continuous automated monitoring of all provider credentials which will detect suspicious activity.

7 Red Flags to Watch for During the Credentialing Process

Trusted credentialing procedures include detailed verification of education, training, licensure, experience, practice, criminal background, exclusions, debarments, etc. A thorough check is rigorous and automatically identifies red flags which may not appear in a more lenient verification process.

These red flags may include (but are not limited to):

  • Vague or no reference responses
  • Voluntary or involuntary relinquishment of licensure
  • Unexplained or inconsistent time gaps or periods of time that are unaccounted for or do not match the timeline reported by organizations with which the applicant was affiliated
  • Frequent employment changes
  • Numerous lawsuits
  • Prior disciplinary action by any other healthcare organization or licensing body
  • Failure to disclose information

Ways to Prevent Negligent Credentialing 

Negligent credentialing lawsuit cases are on the rise and so are the risks and costs that come along with the litigation. Negligent credentialing, a claim of harm or suffering brought against a provider, can result in legal liability when a patient is injured by an incompetent, unqualified, or excluded healthcare provider. This can result in a malpractice lawsuit against the healthcare provider as well as serious financial and administrative consequences for the hospital or medical institution.

Costly negligent credentialing lawsuits can threaten a hospital’s ability to participate in federally funded programs such as Medicare and Medicaid. With growing numbers of negligent credentialing lawsuits, it’s increasingly important for healthcare institutions to verify providers in the early stages of credentialing pre-approval and to continue monitoring providers on an ongoing basis.

In order to prevent negligent credentialing lawsuits, be sure to regularly and thoroughly update your documentation and credentialing processes, conduct regular background checks, check licensure status, check exclusion status, and implement thorough pre-approval screenings with top industry-trusted tools.

Healthcare institutions can minimize risk and maximize patient safety by using tools that keep the guesswork out of critical processes. By integrating real-time tools, you can ensure that providers’ credentials such as education, training, board certifications, licensure, and work history are correct and verified. Verisys tools continue to monitor for any potential red flags or risks after the initial hiring screening is conducted.

Verisys builds real-time solutions that are powered by the healthcare industry’s gold standard in provider data. Find the right tools to support your organization so that you can reduce risk and continue providing the highest level of patient care.

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