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.
Although credentialing and privileging are sometimes used interchangeably, they are different processes. Hospital credentialing, which happens first, verifies the qualifications of a provider. After credentialing, privileging grants the provider the authority to practice medicine at that site.
Before physicians can provide services, their credentials must be verified to ensure they are competent and legally qualified to practice. During hospital credentialing, the hospital requests information from the provider about the provider’s education, work experience, licensure, medical training, insurance, and background. It then verifies that the provider’s credentials are accurate, genuine, current, and in good standing.
How Does the Hospital Credentialing Process Work?
In 1951, the Joint Commission was formed to formalize hospital quality standards. Since the creation of its first accreditation standards manual, the commission requires hospitals to form credentialing committees that oversee physician competence and conduct regular reviews.
Each medical institution can follow its own methods for collecting and verifying the information; however, the same documentation is required each time. Once a hospital receives a physician’s application to work at the hospital, whether the physician is a new doctor or has moved from a different location, the staff begins requesting documentation and verifying the documentation using primary sources.
This 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
Provider credentialing can also include background checks and sanction checks with the Office of Inspector General (OIG). Verification of documentation usually requires contacting primary sources and cross-checking records for consistency. These tasks can be performed by medical office staff or by third-party contractors such as credentials verification organizations employed by the hospital.
Once documentation is verified, the hospital sends the applicant’s files to an executive committee. At this point, the committee may meet with the applicant to discuss the application with stakeholders. The committee then approves the application and sends the information to the Joint Commission.
Types of Hospital Privileging
Once a hospital receives approval for a physician’s hospital credentials, it may grant privileges for that physician to practice at the hospital. Privileging gives authorization for a specific scope of practice within a hospital. There are three types of hospital privileging: 1) active or admitting 2) courtesy and 3) surgical.
- Active or admitting privileging allows a physician to admit patients into the hospital.
- Courtesy privileging allows a physician to admit or treat patients on a limited basis, often as a consultant.
- Surgical privileging allows a physician to perform surgeries, either in the operating room or as an outpatient.
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 the ongoing pandemic, where staffing and financial resources normally used for credentialing are diverted to the care of 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 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
Hospital credentialing is necessary to maintain high-quality patient care, but it can be a long and complicated process. Credentialing and privileging can cause delays in bringing on new providers and can be especially costly for smaller hospitals and telehealth practitioners. Missteps in the process can cause further costs and delays.
Credentialing help is available. With services such as end-to-end provider credentialing, primary source verification, continuous monitoring, and background checking, Verisys saves hospitals time and money. Our technology and data help your credentialing process go smoothly so that you and your patients are protected. By accurately verifying a provider’s credentials and monitoring those providers to ensure ongoing compliance, Verisys assists hospitals, healthcare clinics, pharmacies, telehealth, and more to comply with credentialing standards and keep patients safe. Visit verisys.com to learn more.
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Written by Verisys Verisys transforms provider data, workforce data, and relationship management. Healthcare, life science, and background screening organizations rely on our comprehensive solutions to discover their true potential. Visit verisys.com to learn how we turn problems into power.
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