How Does Medical Credentialing Work?
How does the credentialing process work?
Basically, there are three primary stages:
- In the initial stage (credentialing on-boarding), a healthcare facility or health insurance plan asks the medical provider for information on his or her background, including education, licensing, etc. Hospitals and similar healthcare organizations have a legal obligation to validate the provider’s identity, education, work experience, malpractice history (if any), professional sanctions and license confirmations to safeguard patients from non-qualified providers. As a prime example, when a physician wishes to practice within a hospital, a surgery center or a physicians’ organization, they are required to complete an application and grant permission to a credentialing authority to examine their professional documents. For a doctor, the National Provider Identifier (NPI)**, CAQH ProView, professional licenses, diplomas, certificates and professional references are all considered as credentialing documents. Remember, the process of credentialing is to verify the accuracy and precise data in the physician’s documents.** Every physician receives one National Provider Identifier (NPI) number in his or her lifetime. It is a 10-digit number given only to healthcare service providers. Each provider is then responsible to apply for and update the information associated with their NPI.
- In stage two, this information is confirmed. This is the “background” work where the facility or insurance company will communicate with licensing agencies, medical schools and other such bodies to validate the provider’s information. More recently, the Affordable Care Act substantially increased physician credentialing requirements for Medicare and Medicaid enrollment in an effort to reduce fraud and abuse.
- Stage three is where the provider is presented with credentials from a hospital or other healthcare organization after all required documentation is substantiated and no negative issues are found. The same with insurance companies who can decide to accept a provider as an in-network provider and will pay he or she for treating patients who have its insurance. Keep in mind that with Medicare and Medicaid, medical credentialing is not only concerned with guarding patients, but also deals with providers securing insurance reimbursements. Without insurance credentialing, providers cannot receive patients or clients that are covered by programs including CMS/Medicare and Medicaid, as well as most commercial plans.