Medical Provider Credentialing 101

Jan 11, 2022 | Credentialing

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

The Vendidad 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 lifetime. While the modern process of physician credentialing has changed substantially since then, the weight and importance of it have not.

What Is Medical Credentialing Today?

Modern medical credentialing requires more comprehensive provider data and exclusion screening rather than the treatment of “test” patients. Today, medical credentialing requires the thorough review of a practitioner’s professional medical data including their:

  • Education
  • Training
  • Residency
  • Licensing
  • Certificates
  • Qualifications
  • Work History

Medical credentialing carefully reviews a healthcare provider’s qualifications to practice. Credentialing must be completed before hiring and should be consistently monitored to stay compliant with industry regulations.

To keep a medical provider’s credentials current, medical credentialing must be completed multiple times throughout a provider’s career and must meet all the requirements established by the National Committee for Quality Assurance (NCQA) and The Joint Commission (TJC). Although medical credentialing can be labor-intensive, time-consuming, tedious, and costly for some organizations to handle on their own, it’s a legal requirement. For organizations with overburdened medical staff and limited resources, it’s helpful to have a Credentials Verification Organization (CVO) like Verisys to handle the task of credentialing your staff.

13 Criteria for Effective Medical Credentialing

Verifying your providers against the following 13 criteria will help you evaluate if they are qualified to provide healthcare services:

  1. Evidence of Identity
  • Government-issued photo identification
  • National Provider Identifier (NPI) number
  • I-9 documentation listed as List A or List B or List C as defined on the form
  • Visa or employment verification card
  1. Education and Training
  1. Military Service
  • DD 214 if recently discharged; a complete list of military experience, including military branch and enlistment dates, if currently enrolled.
  1. Professional Licensure
  • Complete list and/or copies of all professional licensure. These must include issuing state, license type, license number, status, and issue and expiration dates.
  1. DEA Registration and State DPS and CDS Certifications
  • Full list and/or copies of Drug Enforcement Administration (DEA), Department of Public Safety (DPS), and/or Controlled Dangerous Substances (CDS) certificates. These must include issuing state, status, registration number, and issue and expiration dates.
  1. Board Certification
  • Full list of Board-specialty certifications held, including original, recertification, and expiration dates.
  1. Affiliation and Work History
  • Chronological, comprehensive list of all facilities where the provider has worked or had clinical privileges (academic appointments, hospitals, practice groups, surgery centers, etc.). These must include start date, date on staff, employment or staff status, verification or good standing, and end date.
  • Explanation of any time gaps
  1. Criminal Background Disclosure
  • Federal, state, and county databases
  1. Sanctions Disclosure
  • Federal and state
  1. Health Status
  • Records of physical or mental illness that could affect work
  1. NPDB
  • Healthcare-specific information on state/federal criminal convictions or civil judgments
  • Malpractice history and hospital sanctions
  1. Malpractice Insurance
  • Comprehensive list of insurance carriers. This includes coverage dates and types.
  • List of open, pending settled, closed, and dismissed cases
  • Current Certificate of Insurance (COI)
  1. Professional References
  • Professional references describing the provider’s current competence

When Do You Need Medical Credentialing?

When starting a new practice, being hired by a new organization, or changing states, medical practitioners must undergo the processes of medical 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

Medical credentialing can be time-consuming and difficult to navigate. Use Verisys technology to automate and simplify your credentialing processes.

Verisys 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.

  • Secure, configurable, and proven solutions
  • Accurate, compliant, and complete information
  • NCQA, URAC, and ISO accreditations/certifications

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