Credentialing

Medical credentialing is the process of verifying a physician’s qualifications, education, certification, and license to practice medicine. It is a way to confirm that the physician has the necessary skills and expertise in their specialty and meets the standards of their state. Medical credentialing is also known as physician credentialing or doctor credentialing. It applies to other healthcare providers as well, such as nurses, but may have different requirements.

The credentialing process usually takes between 90-120 days, start to finish. Because of this, if you are getting ready to start a private practice, don’t wait until the week before you open your doors to start the process!

Getting credentialed, especially in the context of healthcare, is crucial for several reasons:

• Legal and Regulatory Requirements: Many healthcare providers, including physicians, nurse practitioners, and other allied health professionals, must be credentialed with insurance companies and government healthcare programs (like Medicare and Medicaid) to legally provide and bill for services. This ensures that you are authorized to practice in your specialty and that your services are reimbursable.
• Insurance Reimbursement: Credentialing with insurance companies is necessary to be recognized as a provider eligible for reimbursement. Without proper credentialing, insurance companies may reject claims for payment, leaving you or your patients responsible for the costs. Credentialing ensures that you can bill insurance companies directly for services rendered.
• Patient Trust and Confidence: Being credentialed signifies to patients that you meet certain standards of competency and professionalism. Patients often look for healthcare providers who are in-network with their insurance plans, as this can lower their out-of-pocket costs. Being credentialed helps build trust with patients and makes your services more accessible.
• Maintaining Professional Standards: Credentialing typically involves verifying your education, training, licensure, and sometimes your experience. This process ensures that you meet the standards set by insurance companies and regulatory bodies, demonstrating your qualifications to provide safe and effective care.
• Access to Hospital Privileges: If you work in a hospital or healthcare facility, credentialing is usually required to obtain privileges to admit and treat patients there. Hospitals need assurance that you are qualified and competent to provide care to their patients.
• Continuity of Care: Proper credentialing helps ensure that there are no interruptions in patient care due to billing issues or regulatory non-compliance. This allows you to focus on patient treatment and outcomes without administrative obstacles.
  In summary, getting credentialed is essential for legal compliance, insurance reimbursement, maintaining patient trust, accessing hospital privileges, and ensuring continuity of care. It’s a critical step in establishing yourself as a professional healthcare provider.
  

There are numerous important objectives behind the process of medical credentialing — many of them rooted in compliance. Here’s a look at some of the reasons it’s so important, and why healthcare organizations need to prioritize ongoing credentialing:

• Verify the education and training of healthcare professionals. This includes confirming their medical degrees, specialty training, and completion of residency and fellowship programs.
• Validate licensure and certifications. Credentialing organizations verify that healthcare providers hold valid and unrestricted licenses to practice medicine and any additional certifications relevant to their specialties.
• Review professional practice history. This involves checking for any disciplinary actions, malpractice claims, or adverse events related to the provider’s practice.
• Assess professional competence. Credentialing experts evaluate the provider’s clinical skills, experience, and adherence to professional standards.