Essential Documents Needed for Hospital Credentialing

Healthcare providers have always been essential components of society, serving human beings for the betterment of humanity while risking their well-being. They aim to provide quality care to their patients. Those providers who want to be affiliated with an insurer company have to go through a verification process known as the Hospital Credentialing process. 

In this blog, we will uncover the physician credentialing checklist and other processes related to provider enrollment.

 

What is hospital credentialing?

In the healthcare industry, Hospital credentialing, often called healthcare credentialing, is a process where healthcare facilities review and verify the qualifications, skills, and experience of medical professionals. This process ensures they meet the necessary standards to provide care at the facility, protecting patient safety and maintaining high-quality care. Hospital credentialing is critical because it ensures that providers meet the necessary qualifications and standards to deliver safe and effective care to patients.

 

The hospital credentialing process includes verifying the following:

 

• Education and training (medical school, residency, etc.)
• Licensing and certifications (board certifications, state licenses)
• Work history (past practice locations and roles)
• Malpractice history and insurance coverage
• Criminal background and sanction checks
• Immunization records and ongoing professional development

 

Credentialing vs. Hospital Privileging: What’s the Difference?

Although credentialing and privileging are often used interchangeably, they have distinct purposes in the healthcare setting.

 

Credentialing:

Credentialing is the process of determining whether a healthcare provider has the necessary qualifications to perform certain medical services. It is the first step in the process, which also includes verifying the provider’s qualifications, licensure, work history, and certification.

 

Privileging: 

Privileging refers to granting provider-specific privileges, such as admitting patients, performing surgeries, or providing specialized treatments at the hospital. Privileging is based on the provider’s credentialing information and determines the scope of their practice within the hospital.

 

To summarize:

Credentialing	Privileging
Verifies qualifications	Grants authorization to practice
Reviews education, licensure, experience	Allows specific scope of practice (surgery, admitting, etc.)
Required for all providers	Specific to medical services offered

 

Hospital Credentialing Process for Physicians

The physician credentialing process has many steps, each crucial. These steps ensure that providers meet regulatory standards and are truly qualified to work within a hospital or healthcare organization.

 

Steps in the Credentialing Process:

• Initial Application Submission

 

The first step is for the physician to submit a credentialing application, which includes personal information, education history, medical licensure, and malpractice insurance. A survey by the Medical Group Management Association (MGMA) revealed that 68% of medical practices experienced prior authorization denials due to missing information.

• Primary Source Verification:

 

Once the application is submitted, the healthcare organization verifies the submitted information through primary sources, such as contacting schools, licensing boards, and employers.

• Review of Credentials:

 

After verification, a credentialing committee or third-party credentials verification organization (CVO) evaluates the information, ensuring it aligns with regulatory standards.

• Committee Approval:

 

Once reviewed, the application is sent to an executive committee for approval. The committee may discuss the provider’s qualifications further, after which they will be granted hospital privileges based on their credentialing status.

• Final Decision:

 

Upon approval, the healthcare organization may grant the physician permission to treat patients within specific areas of the hospital or healthcare facility.

 

Credentialing process flow chart:

 

Re-credentialing: 

Re-credentialing is a core component of the credentialing cycle. Most healthcare organizations require providers to go through re-credentialing after 2-3 years. Which aims to ensure that the physician remains compliant with the regulatory policies of the government or organization, maintains competencies, and adheres to the evolving educational requirements. 

During re-credentialing, providers will be asked to submit updated information, including:

• Work history
• Malpractice insurance records
• Continuing Medical Education (CME) certificates
• Updated hospital privileges and facility affiliations
• Criminal background check (if applicable)

Document Checklist for Hospital Credentialing

 

Document	Required By
Personal information (email, phone, address)	All healthcare providers
National Provider Identifier (NPI) number	Insurance companies and hospitals
Copy of current medical license	Hospitals and state boards
Medical school diploma & training certificates	Hospitals and credentialing bodies
Malpractice history & insurance coverage	Hospitals, insurance companies
Current curriculum vitae (CV)	Hospitals, credentialing organizations
ACLS/BLS certifications	Hospitals, insurance companies
Copies of current immunization records	Hospitals and clinics

How to Credential with Insurance Companies

Credentialing with insurance companies follows a similar process to hospital credentialing. The main difference between these two is the verification requirements and policies of insurance companies. Providers must be credentialed with each insurance company before they can bill for services under that insurer’s plan.

In some cases, centralized databases like CAQH (Coalition for Affordable Quality Healthcare) can improve the process by allowing providers to update their credentials in one place and share them with multiple insurers. This significantly reduces the administrative burden and speeds up the process.

Common Challenges in the Credentialing Process:

The Hospital credentialing process also has some challenges:

 

1. Incomplete application:

The root cause of denial is insufficient information in the application, such as work history, qualification, or licensure. MGMA studies have shown that a significant percentage of prior authorization denials occur due to missing or incomplete information. 

2. State-Specific Regulations:

Regulations vary from state to state and taking into account such requirements is essential for a provider. Staying informed about the regulatory changes of credentialing is a core. NAMSS, a leading authority in medical staff services, emphasizes the significant variations in state-specific credentialing regulations. 

3. Organizational Misunderstandings:

Credentialing cannot be transferred from one organization to another. Some people assume this is wrong, but each organization has to do its credentialing process. The National Association of Medical Staff Services (NAMSS) strongly emphasizes that credentialing is not transferable between organizations. 

4. Credentialing by Proxy: 

For telehealth and remote providers, credentialing by proxy can expedite the process. This process allows providers to practice at distant sites under the supervision of an originating hospital, reducing the credentialing burden.

 

Final thought:

 

Hospital credentialing may seem complicated, but it is essential for ensuring patient safety and compliance with government legal policies. By understanding the steps involved, maintaining an up-to-date document checklist, and improving technology such as CAQH, healthcare providers can more easily manage the credentialing process.

For healthcare providers, timely and accurate credentialing ensures they remain compliant with industry standards, allowing them to focus on what matters most: delivering high-quality care to their patients.

 

Outsource to Health Quest:

 

Outsource to Health Quest to avail the best billing and coding services. Our certified team ensures compliance with the evolving regulatory policies of the organization, having insight into various requirements related to credentialing. 

For further assistance with hospital credentialing or to discuss essential documents in detail, feel free to contact us at
(415) 508-6537.