With healthcare organizations facing mounting challenges in delivering effective patient care, many need help with physician credentialing. This process is often checked and has a lengthy verification period. As a result, healthcare organizations may need help onboarding new physicians quickly, causing costly and disruptive delays in patient care.
This guide will explore the physician credentialing process and its importance to provider credentialing. We’ll also offer valuable insights to help healthcare organizations achieve their objectives, such as allowing them to streamline the process with innovative data management.
One solution to improve the efficiency and effectiveness of the physician credentialing process lies with Azulity’s provider credentialing services. Our services help healthcare organizations achieve their goals by optimizing data management procedures to reduce redundancy, eliminate errors, and shorten turnaround times so qualified physicians can get to work sooner.
What is Physician Credentialing?
Physician credentialing verifies and assesses the qualifications, training, experience, and professional background of physicians and other healthcare providers. It’s a crucial step in ensuring that healthcare professionals meet the regulatory requirements to practice medicine.
Credentialing ensures that providers meet competency, professionalism, and ethical standards before working with patients. The process involves collecting and verifying relevant documents, conducting background checks, contacting references, and assessing the information gathered.
This includes primary source verification of various aspects, including:
Education and Training
Verification of medical school degrees, post-graduate training programs, and any specialized certifications or fellowships.
Licensure
Confirmation of the physician’s medical license, including its validity and any restrictions or disciplinary actions associated with it.
Board Certification
Assessment of board certifications obtained by the physician from recognized medical specialty boards.
Work History
Review the physician’s employment history, including previous positions, clinical experience, and any gaps in employment.
Malpractice History
Investigation of malpractice claims or disciplinary actions filed against the physician, including settlements or judgments.
References
Checking references provided by the physician, such as recommendations from colleagues, supervisors, or mentors.
Hospital Privileges
Evaluation of the physician’s request for hospital privileges, including their ability to meet specific requirements and standards.
Quality Measures
Examination of the physician’s performance data, such as patient outcomes, adherence to clinical guidelines, and peer reviews.
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Importance of Physician Credentialing
Safeguarding Patients with Physician Credentialing
Physician credentialing plays a critical role in protecting patients. The process verifies that physicians have the qualifications, training, and competencies to deliver care safely. By verifying credentials, organizations can identify any areas of concern — malpractice history, disciplinary actions, or educational gaps — that may impact a physician’s ability to provide safe care before a patient is harmed.
Improving Quality of Care through Physician Credentialing
Physician credentialing helps maintain and improve high standards of care. The process establishes a network of qualified healthcare providers by verifying their education, training, board certifications, and clinical performance. This helps organizations identify qualified physicians who meet specific criteria and adhere to professional standards. The better organized a network of providers is, the more smooth the transition of care will be for patients, resulting in better health outcomes.
Ensuring Compliance with Regulatory Mandates
Legislation, regulations, and accreditation bodies require credentialing. It helps ensure that healthcare providers meet the legal and regulatory requirements to practice medicine. Compliance with credentialing standards is essential for healthcare organizations to receive reimbursement and meet regulatory obligations.
Gaining Provider Insurance Enrollment and Reimbursement
Insurance companies require credentialing as a prerequisite for physicians to participate in their networks and receive reimbursement for services rendered. Credentialing helps insurers assess the qualifications and competence of healthcare providers, ensuring that they meet specific standards before allowing them to provide care to insured patients.
Obtaining Hospital Privileges
Many hospitals and healthcare facilities require physicians to undergo credentialing before granting them privileges to practice. This process helps ensure physicians meet hospital standards for safe and effective patient care. Physicians often need credentials to admit patients, perform procedures, and access hospital resources.
Building Trust and Transparency in Healthcare
Credentialing contributes to establishing and maintaining a physician’s professional reputation. Organizations can identify discrepancies or issues affecting a physician’s reputation by verifying credentials and conducting background checks. Credentialing helps promote transparency and trust among patients, colleagues, and the healthcare community.
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!
Challenges of Physician Credentialing
1. Insufficient Staff for Credential Verification
Credentialing healthcare providers can be tedious and time-consuming. The process requires gathering data from multiple sources, including the provider’s training institution, state licensing boards, and professional organizations. Many organizations need more staff dedicated to this process.
What’s the fix?
Outsourcing the credentialing process to a company specializing in this can help immensely. This frees up staff time to focus on other tasks. Using technology to automate the process as much as possible can also help.
2. Gaps and Errors in Data
Another challenge of the credentialing process is ensuring that only complete or accurate data is provided. This can happen for various reasons, such as human error or outdated information in the provider’s file.
What’s the fix?
To overcome this issue, healthcare organizations should have a system for regularly verifying and updating provider information. They should also cross-check data from different sources to ensure its accuracy.
3. Standardization Issues
There is no one standardized way to credential providers. Different organizations have different requirements, and these requirements can change over time. This can make it difficult for healthcare organizations to keep up with the latest standards.
What’s the fix?
One way to overcome this issue is to work with a credentialing company that can help keep track of the latest standards. Another solution is to develop internal guidelines and procedures for credentialing that can be easily updated as standards change.
4. Provider Turnover
When providers leave an organization, their credentials often need to be re-verified. This can be an arduous, costly process.
What’s the fix?
One way to reduce the impact of provider turnover is to develop a system for tracking provider credentials. This way, when a provider leaves, the organization can easily retrieve and update its information. Another solution is to have a policy that requires providers to keep their credentials up-to-date.
5. Misunderstanding the Credentialing Process
Many healthcare providers need to become more familiar with the credentialing process and help understand what is required of them. This can lead to delays or even errors in the submitted information.
What’s the fix?
One way to overcome this issue is to provide providers with training on the credentialing process. This can help them understand what is required and how to submit their information correctly. Another solution is to have a dedicated staff member who can help guide providers through the process.
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7 Tips for Efficient Physician Credentialing Process
1. Leverage Advanced Technology for Effective Physician Credentialing
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. Implement Peer Reviews to Improve Credentialing
Implement a system for peer reviews as part of the credentialing process to ensure that all practitioners meet the facility’s standards for quality care.
3. Standardize Credentialing Processes
Develop and maintain standardized protocols for every step of the credentialing process to ensure consistency and compliance across your organization.
4. Stay Up to Date on Credentialing Regulations
Healthcare regulations and credentialing standards are continually evolving. Those involved in credentialing must stay informed about the latest updates and changes. Regular training sessions, workshops, or webinars can keep your team aware and adept at meeting new standards, thus enhancing your credentialing process’s overall efficiency and compliance.
5. Digitize Credentialing Documents
Store all credentialing documents, such as diplomas, licenses, and DEA documents, in a digital format for easy access and management.
6. Anticipate the Need for a DEA Number
Secure a DEA number for prescribing medications early in the credentialing process. Apply for this credential in advance to avoid delays, especially when multiple states are involved.
7. Track Provider Credentials for Expirations and Renewals
Implement a systematic tracking system to monitor all credentials’ expiration and renewal dates continuously. This can involve specialized credential management software that automatically alerts the credentialing team well before deadlines, ensuring that every credential falls out of compliance due to oversight.
Book a Call to Learn More About Our Provider Credentialing Services
Provider credentialing is obtaining, verifying, and assessing a healthcare provider’s education, training, residency, and other qualifications to determine whether they are privileged to provide care within a particular organization or network.
The primary goal of the credentialing process is to ensure that patients receive care from qualified providers. It also helps healthcare organizations mitigate risk and avoid legal and financial repercussions associated with poor-quality care.
Why Is Credentialing Important?
Credentialing is essential for both quality patient care and organizational efficiency. The process helps healthcare organizations confirm that their providers have the qualifications to deliver care, which in turn helps improve patient safety and outcomes.
Moreover, credentialing helps organizations comply with regulatory standards and accreditation requirements. Properly credentialing providers can ensure the quality of care and organizational compliance.
What Is the Credentialing Process?
While the specifics of the credentialing process can vary by organization, the following steps provide a general overview:
1. Application
The healthcare provider applies to the organization. This may be done electronically or via paper forms.
2. Verification
The organization verifies the information on the application. This may include contacting references, confirming education and training, and checking for malpractice or disciplinary action history.
3. Evaluation
After verification, the organization evaluates the provider’s qualifications to determine whether they meet the criteria for the desired privileges.
4. Approval
If the provider meets the requirements, they are granted the appropriate privileges. If not, the organization may offer the provider lesser privileges or deny approval altogether.
How Long Does Credentialing Take?
The time it takes to complete the credentialing process varies depending on several factors, including organization policies, state laws, and the provider’s specialty. On average, it takes between 90 and 120 days. However, delays are common and can extend the process by many months.
What Are the Benefits of Provider Credentialing?
Credentialing is an essential process that helps healthcare organizations confirm that their providers are qualified to deliver care. The benefits of credentialing include:
- Improved patient safety and quality of care
- Compliance with regulatory and accreditation standards
- Reduced risk of lawsuits and financial penalties
- Enhanced organizational reputation
- Streamlined operations and improved staff satisfaction
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!