Healthcare credentialing is crucial for high-end medical organizations. By achieving the qualifications necessary, healthcare credentialing may provide clinical privileges in addition to career advancement.

Introduction

Without the right healthcare credentials, patients may be less likely to trust their providers. Since trust is the foundation of a doctor/patient relationship, additional qualifications may be necessary for patients to open up. Once trust has been established, patients are more likely to ask questions about their medical care.

Physicians also benefit from credentialing. Certain credentials will help doctors partner with insurance companies. This allows physicians a chance for reimbursement so that financial losses do not occur.

When regular credentialing is part of a physician’s career, it helps maintain the integrity of practice. Up-to-date education prepares doctors for growing health concerns and modern treatments.

What Is Healthcare Credentialing?

Healthcare credentialing is often used to secure a job with a specific facility. Employers prefer healthcare workers that have the correct credentials to verify they are trained and licensed to practice.

The process of credentialing includes identifying a physician’s residency, career history, education, and any specialty certificates acquired along the way. A healthcare provider is responsible for obtaining this information for the credentialing organization.

The guidelines for credentialing may vary. While hospitals used to be the only facility that could perform credentialing, private practices and clinics are now allowed.

Key Steps in Healthcare Credentialing

There are multiple types of credentialing available. These categories can be referred to as medical credentialing or physician credentialing.

Necessary Documents For Medical Credentialing

• Updated resume
• State Medical License
• Any current certificates such as NRP or ATLS
• Federal DEA
• NPI Number Confirmation
• Current ID
• Medical school diploma

Without the right documentation, it will be difficult to get credentialed. Most of the time errors in accreditation are made because of easily-avoidable mistakes. Incorrect data entry, presenting the wrong documentation, or failing to complete the entire document will delay progress.

Provider Enrollment vs. Credentialing: What’s the Difference?

An out-of-network healthcare provider is expensive. Because insurance is not accepted, many patients choose to find a different physician. In order to be in-network, a physician must be enrolled with a specific health plan.

The enrollment process begins with a provider specialist. The provider enrollment specialist will decide who does and does not need to be credentialed. Certain mid-level providers may not need to be credentialed in which case the provider enrollment saves time.

Provider credentialing requires an application with all the proper documents. This information is verified for authenticity. The process includes an overall search for malpractice claims in the National Practitioner Data Bank. Once the physician’s record is thoroughly examined, it can be officially approved.

Important Checklist for Provider Credentialing

In addition to medical degrees and identification, healthcare providers will need proof of specific vaccines.

These vaccines are commonly used throughout the world and keep physicians from potentially spreading disease. Immunization records will prove that basic vaccines for Hepatitis B, Measles, Tetanus, and Varicella have been received. Some of these vaccines may need to be updated before an application is sent to the credentialing team.

As for references, make sure to include their full name, phone number, and email along with their specialty. The location and time of employment must be noted for colleagues. Provider enrollment and credentialing services come in handy for the application process.

Provider Credentialing Checklist

The healthcare credentialing process requires many of the same documents as the hospital credentialing process. These documents are official and will be thoroughly examined by several individuals in the industry.

To successfully fill out the healthcare provider credentialing application, make sure you have the following documentation:

• Graduate or medical school diploma
• Mammo #s and MQSA
• ECFMG certificate
• State-controlled substance registrations
• Malpractice claims history
• Medical license

The provider credentialing process can take time, especially for new healthcare providers. Before sending in an application, it’s important to review and revise as many times as needed.