Credentialing 101: What is Provider Credentialing?

October 7, 2021by Sherana Tucker

What is Provider Credentialing?

Credentialing is the process of verifying the professional qualifications of medical providers and is required by most medical facilities and services, including hospitals and health insurance companies. Analyzing the provider’s documents through a credentialing process guarantees that they are both legitimate and up-to-date.

Credentialing also allows for full transparency and trust between the patient, the healthcare provider, and the organization. This seeks to verify competency while minimizing the likelihood of future medical errors.

Our credentialing team can offer guidance to both new and existing providers, as the hospital credentialing process must be completed every 2 years. We will notify you of any expiring licensure and certifications, populate your credentialing applications for you, manage your documents, and alert you when hospital reappointment is due.

What is Required for Credentialing?

Although the credentialing process is initiated by the healthcare organization, the responsibility ultimately begins with the provider. They are responsible for getting the required information to the credentialing professional who will be overseeing the process.
The credentialing process includes verifying information such as:

  • Personal Information
  • Education and Training
  • Licenses and certifications
  • Attestations (health, CME, etc.)
  • Current hospital privileges
  • Current practice history
  • Malpractice insurance & claims history
  • Professional references

What Kinds of Facilities Need Credentialing?

It is not only practitioners but facilities themselves that need to maintain standards of care and competence. The following kinds of facilities and services are obliged to acquire and maintain the proper credentials to act as healthcare providers include:

  • Hospitals + Urgent Care Facilities
  • Ambulatory + Surgical Centers
  • Hospice Facilities
  • Diagnostic Testing Facilities
  • Laboratories and Laboratory Collection Sites
  • Prosthetics/Orthotics
  • Radiology/Diagnostic Imaging

By credentialing facilities as well as health care practitioners, the system adds an extra layer of protection for patients.

Let CredentialPro focus on the paperwork, so you can focus on your patients.

What does the Credentialing Process Consist of?

The provider credentialing process is completed in stages, and it begins with the gathering of information from many sources, including the provider—a step that often includes significant follow-up efforts.

Once this step is complete, the information is checked for accuracy and legitimacy. Primary Source Verification (PSV) of all of the data and documents collected will occur to assess and identify gaps, discrepancies, or “red flags” of any kind. The goal is to guarantee, to the best extent possible, that all data reflects the full portrait of a provider.

In other words: Are you clinically fit, both personally and professionally, to work in the healthcare organization for which you are applying?

You can help ensure this part of the credentialing process runs smoothly by making sure that your application is correct and thoroughly completed with all the necessary supporting documentation. It is important to contact your references and employers to request that they mail, fax or email all verification requests as soon as possible.

Also, if you still have not applied for your state license or it is pending approval, this can seriously delay the process. It is best to wait until your application has been approved before you apply for credentials and privileges, although some hospitals will make an exception depending on how long the license application has been in process.

How Long Can The Credentialing Process Take?

In most cases, the credentialing process can take anywhere from 60-90 days. It can vary depending on what field you seek credentials in, what facility and/or state you are applying to, and whether you have provided them with all the necessary documents and filled out the application correctly.

For this reason, it is normally best to begin the application process 90 days before your start date at a new facility. Ninety days allow for some margin of error, especially with regard to responding to requests for additional information, unexpected delays, or if there are discrepancies that need clarification.

Should You Consult With A Credentialing Company?

Provider credentialing is a time-consuming process where attention to detail is critical. Even the slightest error in the application process can cause major setbacks, which would mean delay or even loss of revenue altogether.
It takes an expert to navigate the credentialing process within specific time constraints, regulatory requirements, AND with minimal errors. CredentialPro will be that expert to ensure a smooth process while eliminating the paperwork, frustration, and time spent navigating the difficulties of the healthcare credentialing process.

Sherana Tucker
655H Fairview Rd, Ste 301 Simpsonville, SC 29680

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