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Did you know provider credentialing is the most crucial process for the reputation of a healthcare organization? There are specific steps that you can execute to refine your patient care. This blog will cover how it works and how hospitals are responsible for it.

We have also discussed the duration and impact of the credentialing process, along with the steps you can take to conduct it smoothly. Continue reading further to learn how you can strengthen your reputation through strong provider credentialing practices.

Additionally, unlock smooth medical billing with our expert Provider Credentialing Services. Ensure accuracy and efficiency.

Provider Credentialing

What is Provider Credentialing?

Provider credentialing is a process in which healthcare organizations evaluate the credentials of their professionals, including qualifications and experience. Sources of medical aptitude like education and licenses are verified to ensure quality patient care. 

For this, you can validate the relevant data, grant privileges, and conduct peer reviews according to the provider’s credentials. You must maintain high standards and regulate compliance with guidelines and policies for the entire process of provider credentialing.

10 Key Steps That Are Must for Provider Credentialing

Medical provider credentialing is a rigorous process in which each step must be executed carefully to ensure accurate verification. Let’s inspect the ten key steps that every healthcare organization must execute to verify the credentials of its medical practitioners.

Provider Credentialing

1. Submitting Applications

As a first step, you must direct all medical practitioners seeking affiliation with your healthcare organizations to submit entry applications. You can utilize these applications as an initial evaluation procedure to assess the qualifications and background of applicants.

The applications must require those applicants to submit their primary details like educational history, work experience, licenses, certifications, and professional references. You can start evaluating the applicants through these details.

You must ensure that a provider credentialing application is accurate, as any inaccuracies can delay provider credentialing or hinder quality patient care. This submission of applications administers the first point of interaction between potential medical practitioners and healthcare organizations.

2. Verifying Primary Sources

Verification of primary sources is a vital step in provider credentialing that ensures the accuracy and authenticity of the information provided by healthcare professionals. For this step, you can contact the original sources of the credentials listed in the provider’s application.

By doing this, you can confirm the validity of the provider’s educational achievements, licensure status, and professional certifications. In this way, you can prevent misrepresentation and ensure quality patient safety while maintaining the credibility of your healthcare institute.

Furthermore, verified primary sources mitigate the risks involved when you rely solely on self-reported information, as it can contain deliberate misstatements. You can ensure that the applicants possess the qualifications required to meet the standards of your organization.

3. Conducting Peer Reviews

By conducting peer reviews, you can robustly evaluate the clinical competence and professional conduct of the applicants. You can form a committee composed of qualified peers from various medical disciplines to thoroughly assess the providers’ capabilities and ethics.

These peer reviews can include an examination of the medical records, patient outcomes, and interactions to gauge their clinical proficiency. You can also direct the peers to inspect the providers’ adherence to established best practices, ethical standards, and guidelines.

This step provides a well-rounded perspective that helps you select the ideal applicants for your healthcare organization. You can use the valuable insights into the providers’ real-world performance to bolster the overall safety and quality of your patient care.

4. Implementing Background Checks

Healthcare provider credentialing also involves implementing background checks in which you can undertake thorough background screenings. This will ensure that the applicants have a clean history and, if appointed, will be suitable to treat your patients.

Background checks oversee criminal records as well, aiming to uncover any misconduct or unethical history that could potentially jeopardize patient welfare. You can uphold the ethical standards of the healthcare environment by scrutinizing such red flags.

This is another effective step to validate your providers’ credibility and instil trust in your patients. You can utilize this opportunity to demonstrate your commitment to maintaining a secure and reliable healthcare environment for all parties involved.

5. Assigning Clinical Privileges

After this, evaluating a provider credential can progress onto the next phase, where you can assign clinical privileges like denial management. The privileges must be based on their verified expertise so that they can appropriately utilize their experience and skill set.

This step also involves determining the scope of medical procedures to authorize those practitioners to perform them on your patients. In this way, you can devise a tailored approach to assign tasks to providers that match their proficiency and enhance patient safety.

By assigning clinical privileges, you can redefine your resource allocation as it enables you to fairly distribute responsibilities among your healthcare professionals. Your patients can be confident in the competency of your providers through their verified credentials.

6. Continuous Monitoring

You must also continuously monitor your healthcare professionals and ensure that they adhere to established standards throughout their tenure. For this, you can conduct regular assessments of their performance and professional conduct to determine the level of their competency.

Through continuous monitoring, healthcare organizations can also effectively manage their providers so that they deliver high-quality care and stay updated with the latest healthcare practices. Chart reviews and patient feedback are good indicators of a provider’s abilities.

In this way, you can drive your medical practitioners to foster a culture of continuous improvement and accountability. This gives them a platform to identify any inaccuracies in their practices, address those issues promptly, and implement mitigative actions.

7. Credentialing Cycles

Healthcare organizations can implement credentialing cycles as a recurring process to check whether the providers maintain their competency over time. For re-credentialing, you can conduct periodic reviews every few years as part of your reporting and analytics process.

By overseeing these credentialing cycles, you can ensure that the medical practitioners working in your healthcare organization follow its quality and safety protocols. You can also identify changes in their background that can hinder their eligibility to practice medicine.

8. Regulating Compliance

Furthermore, you can introduce compliance checks to ensure your healthcare professionals’ compliance with all legal and ethical requirements. With this, you can assure the relevant governing bodies that your organization meets all the set standards and guidelines.

In this process, you can check the validity of licenses and correlate ongoing practices with the standard codes of ethics and regulations. Doing this will protect you from any legal or ethical issues arising from unauthorized practice.

9. Automated Credentialing

As an additional step, you can also invest in setting up software to fulfill the provider credentialing requirements by automating the complex administrative tasks involved. With this digital solution, you can centralize the data entirely and automate relevant workflows.

A credentialing software dynamically gathers and stores extensive provider information and minimizes errors and oversights. This automated system can significantly expedite the verification processes and reduce administrative burdens through real-time updates.

This step can enable you to reduce paperwork and optimize efficiency for smooth collaboration between your employees. In this way, provider credentialing services can be simplified so that you can allocate resources effectively and ensure premium care for your patients.

10. Forming Credentialing Committees

Forming committees to oversee the evaluation of provider credentials is a primary step that enforces thoroughness and objectivity to follow industry standards. You must instruct these committees to comprehensively navigate through this process to uphold organizational integrity.

They can also be charged with reviewing the applications of potential medical practitioners to verify their credentials. You can also add a layer of impartiality to the decision-making process by checking whether the providers meet your stringent criteria.

This is another procedure with which you can maintain compliance with regulatory requirements as well as ensure quality patient care. Your committees can make informed decisions about various significant processes like re-credentialing and granting clinical privileges.

How Does Provider Credentialing Work?

There are three phases in provider credentialing. Let’s take a look at them in detail:

1. Collect Details

Hospitals have to request background details from their healthcare providers. Those details are mostly about their education, licenses, and other professional documents. Their healthcare providers can provide those details through email or questionnaires. Some hospitals also use third-party services to expedite the process.

2. Verify Details

Often, hospitals or insurance companies have to verify the provided details. They can contact the medical schools of their healthcare providers. Other relevant entities are also kept in the loop about those providers’ credentials.

All this cross-checking is necessary to confirm if they are accurate. Some hospitals also check the reports of medical incidents and malpractice claims. Such reports are also key factors for provider credentialing.

3. Credential Awards

After the verification process, hospitals hand out the credentials to their healthcare providers. Insurance companies also conduct reviews to approve healthcare providers. This way, those providers can receive payments for their medical services.

Who Is Responsible for Credentialing?

Every hospital is responsible for ensuring that their healthcare providers are competent. Their provider credentialing process steps should verify the education and training of their staff. You can use the set accreditation standards as a reference. Your healthcare providers must also follow all the state and federal laws.

You must always check the primary source. This way, you can determine the fraudulency of the papers. With a proper credentialing process, you can catch healthcare workers with dubious qualifications. You should audit all of your healthcare practitioners even after credentialing.

Entities That Regulate or Provide Standards for the Credentialing of Providers

There are two main governing bodies for provider credentialing. They are named Centers for Medicare & Medicaid Services and the Joint Commission on Accreditation of Healthcare Organizations. Both of these bodies strictly instruct hospitals to conduct provider credentialing.

You should also conduct it to remain eligible for Medicare and Medicaid reimbursements. The Joint Commission especially accredits only those hospitals that comply with its policies. There are some other groups that set credentialing standards as well. By following those standards, you can receive extra accreditation.

Those groups comprise the National Committee for Quality Assurance. Det Norske Veritas and the Utilization Review Accreditation Commission are also involved. Another group, named The Accreditation Association for Ambulatory Healthcare, has its own standards.

How Long the Credentialing Process Can Take?

The credentialing process can take between 90 and 120 days to complete. It involves in-depth research and has to be accurate. This means that it does not have to be a speedy process. But, verifying the credentials of your healthcare practitioners is essential. So, you must verify the primary source. It can confirm their key characteristics like education, medical training, references, and more.

How Lengthy Processes Can Affect Doctors, Hospitals, and Healthcare?

Lengthy processes cause delays and greatly impact doctors, hospitals, and healthcare systems. Doctors can get stressed and feel burned out due to the intensity of their work. An extended time has to be given to paperwork. There are some long bureaucratic procedures as well. They do not leave behind any time for patient care and well-being.

Hospitals also have to experience delays in their service delivery. As a result, their patient satisfaction levels get heavily reduced. Their healthcare systems are compromised, which affects their overall quality of patient care.

The Role of CAQH In Provider Credentialing

CAQH is a database that contains healthcare practitioners’ records. Those records can be accessed by credentialing companies. These companies pay a specific sum to access CAQH. You do not have to provide updated documents to different insurance companies.

Hospitals can just upload those records to CAQH. You can even upload attested records and give their access permission to insurers. Keep in mind that none of the government payers have authorized CAQH.

This means that they do not use it. As a result, regional and local insurance coverages cannot access your records. This is why it is recommended to always keep the credentialing documents prepared.

How to Ensure the Credentialing Process Goes Smoothly

You can take various steps to conduct a smooth provider credentialing process in healthcare. We have covered the three major steps that can be helpful for any hospital:

1. Background Check

With a background check, you can determine whether the applicants have provided valid details. Such checks detect credentialing problems at an early stage. As a result, you are able to select the ideal healthcare practitioner for your hospital.

2. Early Credentialing Process

Provider credentialing can get lengthy and experience delays. And your reimbursements may take a hit. So, you must start the credentialing process as soon as possible. This gives you extra time to deal with unexpected delays. 

3. Credentialing Coordinator

A credentialing coordinator can manage your credentialing workflow. They can also ensure a timely submission of your documents. Some hospitals assign an employee to perform this task. However, you can also outsource it to an outsourcing company with more expertise. This step can make provider credentialing faster and more accurate.

The Bottom Line

The ten key steps covered in this blog are prime operations that you must execute for an ideal provider credentialing process flow. Provider credentialing collects and verifies the details of healthcare practitioners and awards them with credentials.

A lengthy process can impact your patient care, but you can use CAQH to streamline the access. We at Health Quest Billing can ensure that your provider credentialing goes smoothly. Contact us today to optimize your patient care through a smooth credentialing process.

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Frequently Asked Questions (FAQs)

Credentialing is a formal process that follows specific guidelines to ensure the highest level of professional medical care. It passes healthcare professionals through strict scrutiny to determine their ability to practice medicine.

Provider Enrollment applies health insurance networks to be included in their provider panels. This process has two steps for commercial insurance networks. They are named credentialing and contracting.

A credentialing cycle is a combination of steps that verifies the education, skills, and other key aspects of healthcare practitioners. It ensures that those practitioners have the required licenses and certifications to practice medicine.

System credentialing is a series of processes that appoint established standards to programs, individuals, products, or institutions.

Credentialing documentation is a process in which you can record the details of your healthcare practitioners. Those details can include their personal data along with a recent photograph dated and signed