Credentialing is a formal process to ensure that healthcare professionals have undergone the most stringent scrutiny regarding their ability to practice medicine. Credentialing also assures that the patients are being treated by providers whose qualifications, training, licensure, and ability to practice medicine are acceptable and it also ensures the patients receive the highest level of care. Credentialing also ensures that all healthcare workers are held to the same standard.  

In general, any licensed, independent healthcare professional who has been permitted by law and regulated by a licensing organization to provide services and care without supervision or direction within the scope of the individual’s license needs to be credentialed.  

Only having a healthcare profession license does not mean one can provide any medical service they want. For example, an advanced nurse practitioner cannot independently start prescribing medications, or a family physician cannot begin seeing patients. In certain states, independent nurse practitioners, they work under a physician.  

The credentialing process is tied to the demonstration of proper education and training and maintains accreditation standards reimbursement requirements and satisfies state and federal laws. Credentialing is the process of assessing the academic qualifications and clinical practice history of a healthcare provider. Today several national agencies are dedicated to maintaining the standards of credentialing for healthcare providers. For example, National Committee for Quality Assurance (NCQA) has established a set of standards that currently act as a guideline on how to credential health care providers. 

Yes. Healthcare delivery has evolved rapidly during Covid. Some physicians are now allowed to practice telemedicine within reason. The Centers for Medicare and Medicaid Services are now permitting healthcare institutions whose patients are receiving telemedicine services to grant privileges and credentialing to physicians providing ambulatory surgery care and teleradiology.  

No. Healthcare worker should not be permitted to work before completing the credentialing process.  

The first step is to collect all the documents like practice information, provider certificates and licenses, CV and other documents. Second step is to file the documents with the payers and authorities. Different payers have different requirements of submission. Some of them allow electronic filing, some require paper filing. The third step is to follow-up with the payers and answer any questions or provide them any additional documents needed. This entire process might take upto 90 days. 

Over the past 10 years, healthcare credentialing process has become very complex and time consuming. It is mainly due to expansion of the provider scope of practice, accrediting bodies, and requirements of third-party payers like Medicare, Medicaid, and private insurers. Each of the third-party may have different requirements to credential a healthcare provider. Furthermore, the healthcare institution or licensing board also check with the primary source regarding education and training. The information should also be obtained on any malpractice claims and several other factors that may have an impact on clinical practice. 

Credentialing is a very complex and time-consuming process as it requires interacting with several federal and state agencies and all the payers. It requires a thorough knowledge of the process, maintaining checklists and a rigorous follow-up. It is best to ask a credentialing company that specializes in the process to take care of it. Internal practice staff is unlikely to be aware of all the aspect of credentialing. Any delay in credentialing has a direct impact on revenue as without credentialing with each payer, payers will not make the payment for the claim submitted by the practice. 

After a healthcare provider is credentialed, the next step is to address the privileges of practice, which depend on the evaluation of the provider’s clinical qualifications, training, and overall performance. The privileges should be reviewed every 2 years. This is very important because the provider may have learned new skills they may want to use. For instance, a provider may have taken a course in bariatric surgery and may want to establish a program in the hospital. On the other hand, some providers may be getting old and prone to mistakes, and thus privileges for these surgeons should be limited to only certain procedures. Other providers may have developed an ailment like seizures or Parkinson’s disease, which may mean that they cannot work safely in the operating room, and thus privileges have to be curtailed. All employers have to comply with the Americans with Disabilities Act. The applicant cannot be discriminated against or denied credentialing just because of a disability. 

There are several agencies and organizations that related to credentialing process. Few are listed below: 

National Plan and Provider Enumeration System & NPI Registry: Assigns NPIs, maintain and updates information about health care provider with NPIs. 

Council for Affordable Quality Healthcare (CAQH): CAQH technology-enabled solutions, operating rules and research help 1,000 health plans and 1.6 Million providers, government entities and vendor connect, exchange information and operate more efficiently. 

National Practitioner Data Bank: The NPDB is a US government program that gathers data and provides it to authorized users. The data collected includes negative complaints, malpractice cases, awards, loss of privileges, loss of professional society membership, suspension of license, revocation of a license, or expulsion from participation in Medicaid or Medicare programs. When applying for a license in many states, one has to submit the NPDB data. 

The American Board of Medical Specialties (ABMS) was established in 1933 and is a non-profit organization representing 24 broad disciplines of medicine. The board functions to maintain a rigorous process or evaluation of board certification of American physicians. ABMS certifies over 150 medical specialties. The board also collaborates with other professional medical agencies and organizations to set standards for residents and accreditation of residency programs. The information on ABMS is available to the public. 

American Association of Nurse Practitioners (AANP)/American Nurses Credentialing Center (ANCC) are two separate agencies that also verify if the nurse is board certified. 

The Office of Inspector General (OIG) and the System for Award Management (SAM) are two agencies that also help verify if healthcare providers have any restrictions/sanctions against their medical license that may limit their ability to practice clinical medicine. 

Each state has a medical board that operates a license verification program. These are further separated into nursing, dental, podiatrists, doctor of osteopathy, and physicians/physician assistants.