After weeks of interviews, you finally found the perfect candidate for your organization’s open position. But just as you’re about to extend an offer, you discover that this candidate’s hospital credentialing process could take months—if they even get approved. Because of a previous malpractice claim, your candidate’s credentialing will require additional review—potentially delaying their start date and disrupting patient care at your facility.
Unfortunately, this scenario is all too common in healthcare. Provider credentialing can feel like a game of chance, where the organization and the provider have little control over the outcome. Organizations want to expedite the process as much as possible to bring qualified professionals on board and minimize disruptions to patient care. Meanwhile, the providers often have little to no say in the outcome of their applications.
This guide will discuss hospital credentialing requirements, why they matter, and how understanding them can help you achieve your goals. For example, allowing healthcare organizations to use innovative data management can help improve the efficiency and accuracy of the provider credentialing process.
Azulity’s provider credentialing services, a powerful solution for streamlining credentialing in organizations, can help you achieve these objectives.
What Is Hospital Credentialing?
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 patient quality and safety. Done properly, it protects providers and hospitals. Credentialing and privileging are different processes. Hospital credentialing, which happens first, verifies a provider’s qualifications. After credentialing, privilege 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 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 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 has required hospitals to form credentialing committees that oversee physician competence and conduct regular reviews. Each medical institution can follow its 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,t Updated curriculum vitae ACLS/BLS certification DEA certificate,e 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 third-party contractors, such as by 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.
7 Essential Hospital Credentialing Requirements
1. Education and Training Verification: Confirming the Qualifications of Healthcare Professionals
Hospital credentialing involves verifying the education and training of healthcare professionals. This includes confirming the completion of medical degrees, residencies, fellowships, and any specialized training relevant to their practice. Verification may involve contacting educational institutions, examining transcripts, and reviewing certification documents.
2. Professional Licensure Verification: Validating Medical Licenses
Valid professional licensure is a fundamental requirement for practicing medicine. Hospitals must verify that healthcare professionals possess the necessary licenses to practice in their respective jurisdictions. This involves verifying the status of permits, checking for any disciplinary actions or restrictions, and confirming that licenses are up-to-date.
3. Work History and Employment Verification: Assessing Past Performance
Verifying work history is essential to assess healthcare professionals’ professional experience and track record. Hospitals typically verify past employment, including positions held, dates of employment, and responsibilities. This verification helps evaluate the professional’s expertise and ensure they have the necessary experience to perform specific procedures or provide specialized care.
4. References and Peer Recommendations: Gathering Insights on Competence and Character
Obtaining references and peer recommendations is an integral part of the credentialing process. Hospitals may require candidates to provide references from colleagues, supervisors, or professional associations who can vouch for their competence, professionalism, and ethical behavior. These references provide valuable insights into the candidate’s abilities and character.
5. Malpractice Claims and Disciplinary Actions History: Identifying Potential Risks
Assessing the history of malpractice claims and disciplinary actions is crucial to identifying potential risks for healthcare professionals. Hospitals review the candidate’s history to determine if there have been any previous instances of malpractice allegations or disciplinary actions. This step helps evaluate the practitioner’s adherence to professional standards and commitment to patient safety.
6. Ongoing Professional Competence Assessment: Ensuring Continuous Quality Care
Hospital credentialing goes beyond initial evaluations. It includes ongoing assessments of healthcare professionals’ competence and performance. This may involve peer reviews, evaluations based on clinical outcomes, participation in continuing medical education, and adherence to professional guidelines and best practices. Regular assessments ensure medical staff maintains the necessary skills and knowledge to provide quality care.
7. Criminal Background Checks: Ensuring a Safe Environment for Patients and Staff
Conducting criminal background checks is an essential component of hospital credentialing. Hospitals aim to ensure the safety of patients and staff by verifying that healthcare professionals do not have a history of criminal activity that could compromise patient care or the hospital’s reputation. Screening may include seeking convictions, sanctions, or exclusion from federal healthcare programs.
Azulity specializes in healthcare master data management and provider credentialing services, bringing proven expertise in implementing healthcare data solutions and credentialing across the US. Our comprehensive platform ensures consistent patient, provider, location, and claims data synchronization across all systems and departments.
Key features include healthcare MDM, provider MDM, reference data management, credentialing, and provider enrollment. We serve healthcare technology leaders—from CIOs and CDOs to VPs of data platforms and credentialing—helping them eliminate the costly problems of fragmented data systems. Book a call to learn more about our healthcare master data management services today!
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Importance of Hospital Credentialing
1. Trust is Key: Credentialing Increases Trust
Hospital credentialing positively affects patients’ trust. When hospitals verify the qualifications of healthcare professionals, it assures patients of a practitioner’s skills and experience. This helps patients feel comfortable with their chosen providers.
2. Prevent Revenue Losses with Credentialing
Credentialing helps medical practices avoid losing revenue from delayed or denied reimbursements. When a healthcare professional hasn’t been adequately credentialed, insurance payers might refuse to reimburse medical practices for their treatments. Such losses can be financially devastating.
3. Credentialing Lowers the Risk of Medical Errors
The importance of credentialing for patient safety cannot be overstated. Research shows that about 98,000 Americans die from medical mistakes every year. This shocking statistic has led industry leaders to demand better standards of exposure and competency, as well as disciplinary measures against healthcare professionals. Credentialing for healthcare facilities and independent practitioners lowers the risk of medical errors.
4. Credentialing Protects You from Lawsuits
Hospitals and healthcare organizations can avoid lawsuits by having an accurate and complete record of every practitioner’s credentials. For example, suppose a negligence claim on a healthcare professional in your institution. In that case, you can save your facility from a lawsuit by confirming that you verified all of its credentials as required.
5. The Importance of Credentialing with Insurance Networks
The process takes patience and time. First, you have to decide to proceed with the process. Second, you must shortlist the insurance companies you want to work with. Finally, it’s time to take the first step. Knowing that the credentialing procedure may take a few months is crucial.
Related Reading
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13 Tips for Efficient Hospital Credentialing
1. Use Azulity to Optimize Credentialing Processes
Azulity specializes in healthcare master data management and provider credentialing services, bringing proven expertise in implementing healthcare data solutions and credentialing across the US. Our comprehensive platform ensures consistent patient, provider, location, and claims data synchronization across all systems and departments.
Key features include healthcare MDM, provider MDM, reference data management, credentialing, and provider enrollment. We serve healthcare technology leaders—from CIOs and CDOs to VPs of data platforms and credentialing—helping them eliminate the costly problems of fragmented data systems. Book a call to learn more about our healthcare master data management services today!
2. Begin the Licensing Process Early
For new practitioners, starting the licensing process as soon as possible is critical for a smooth transition from educational programs to practicing. Different licensing processes apply to various types of providers, and each can take a different length of time to complete. For example, Physician Assistants must obtain certification from the National Commission on Certification of Physician Assistants. This certification process can involve several steps, including verifying education and citizenship, and may require peer references.
3. Keep All Physician Contact Information Up to Date
Something as simple as a wrong address for a provider or peer reference can cause problems with medical credentialing. Therefore, ensure that all contact information for physicians or other providers is updated periodically. If clear lines of communication are not available for any given provider, this can slow down processes when a provider’s credentials are up for question by a payer.
4. Outsource Medical Credentialing Services
Medical credentialing can be a time-consuming process. Additionally, slight missteps in the process lead to frustrating issues later. Therefore, working with a medical credentialing service provider like PrognoCIS may be one of the best credentialing tips you can follow. When you outsource provider credentialing with a service like PrognoCIS, a medical credentialing specialist assesses credentials on file for providers within the organization and ensures everything is recorded as it should be.
5. Know Your State’s Regulations
State regulations for medical professionals can vary in terms of credentialing. This is especially important if your organization has providers transitioning from one state to another to provide services. If credentials for that specific state are not updated, this can lead to problems once claims are filed to receive payments from payers for services rendered.
6. Track Credentialing Applications
Once credentialing applications are submitted to an insurance company or organization, be sure to track the progress of that application. Don’t hesitate to check in with an insurance company to find out where an application is in the acceptance process. It is not uncommon for payers to set aside applications that are missing information and delay alerting providers promptly.
7. Avoid Common Errors
As simple as it sounds, an essential medical credentialing best practice tip is to be mindful of common errors. Standard errors are most likely to disrupt the credentialing process with a provider. Physician’s Practice states that as many as 85 percent of credentialing applications are missing must-have information the payer has to have to process the application. This can include:
- Lack of peer reference contacts or contact information for those contacts
- Improperly filled-out credential forms or missing information
- Submitting an expired NPI or DEA number
- Missing gaps in malpractice history
- Lack of clinical history documentation
- Data entry typos or mistakes
8. Keep Digital Files
Hard copies of credentialing files are essential, but keeping at least one digital file where all credentialing documents can be stored is just as vital. This is an essential medical credentialing best practice to remember because it can save time later. When a payer requests credentials, you will have one transparent file where everything is digitally available. Be sure to include diplomas, state licenses, DEA documents, passports, driver’s licenses, and anything else used for credentialing experience or identity.
9. Obtain a Dedicated DEA Number
DEA (Drug Enforcement Administration) numbers are mandated for providers to prescribe medication. Providers typically need a number for each state where they intend to provide services, but requirements vary. It can take several weeks for applications for DEA numbers to be processed after applying through the DEA website.
10. Get an NPI Number
National Provider Identifiers (NPIs) are assigned to care providers, but the provider must also keep NPI information current. If a provider has an NPI or their information is accurate, this is a common reason for the claim to be denied by payers. Therefore, any time a practitioner’s status changes, the National Plan and Provider Enumeration System (NPPES) must be updated through the NPPES website.
11. Request Procedure Logs & Clinical History
Clinical history is a common requirement for proof of work history in healthcare. To prove clinical history for any provider, request procedure or activity logs and keep them on file. Whichever department is responsible for billing for a provider’s services can usually offer an activity log that can be used for clinical history documentation.
12. Examine Malpractice Claims
An extensive record of previous claims filed, records of insurers, and policy numbers for malpractice insurance should be kept on file with credentialing information. Make sure new providers have a certificate of insurance on file as well.
13. Track Progress Using Advanced Software for Monitoring
A provider’s credential file can involve licenses, numeric identifiers, and forms of identification that face expiration dates. If these documents expire without notice, this can generate problems with credentialing. Be sure to track expiration dates on each provider’s credentials in the organization. This ensures that documents that are soon out of date are updated on time without disruptions.
Book a Call to Learn More About Our Provider Credentialing Services
Credentialing is key to any medical, healthcare, or hospital operation. It allows for patient care’s smooth and quality delivery and ensures compliance with various regulations and payor requirements. Hospital credentialing requirements and processes differ based on the organization and the state where the facility operates.
In general, hospitals and other healthcare organizations credential medical staff and practitioners before they can provide patient care in their facilities. This process helps organizations verify that the individual’s licenses, education, and certifications are current and meet the hospital’s standards and regulatory requirements. The method also involves thorough background checks to ensure the safety of patients.
Once a practitioner is granted privileges, the hospital must continuously monitor their performance and adherence to standards and regulations. Additionally, the practitioner must be re-credentialed after a certain period, typically every two to three years. Azulity can help streamline the hospital credentialing requirements specific to your organization with our comprehensive data management solutions.
Who Is Affected By Hospital Credentialing Requirements?
The hospital credentialing process affects both practitioners and the organization itself. Practitioners must provide extensive documentation and evidence of their qualifications to obtain privileges to practice at a specific facility. This can be lengthy and stressful, especially for those relocating and needing to start working as soon as possible. Hospital credentialing requirements can also impact patient care. Practitioners must be granted privileges before they can provide medical treatment to patients at the facility.
This can lead to care delays, adversely affecting patient outcomes. The credentialing process is necessary for the organization to ensure quality care and compliance. However, without a streamlined approach, the process can take significant time and involve much manual work, leading to costly errors and operational inefficiencies. Azulity can alleviate the burden of the credentialing process for practitioners and healthcare organizations.
How Does Azulity Help With Hospital Credentialing Requirements?
Azulity specializes in healthcare master data management and provider credentialing services, bringing proven expertise in implementing healthcare data solutions and credentialing across the US. Our comprehensive platform ensures consistent patient, provider, location, and claims data synchronization across all systems and departments.
Key features include healthcare MDM, provider MDM, reference data management, credentialing, and provider enrollment. We serve healthcare technology leaders, from CIOs and CDOs to VPs of data platforms and credentialing, helping them eliminate the costly problems of fragmented data systems. Book a call to learn more about our healthcare master data management services today!