Healthcare provider credentialing involves many parties and all basic educational information. Healthcare providers all need to prove their education, skills, and training required to see patients. Simultaneously, healthcare oversight organizations monitor the work of medical providers to evaluate reports of improper care, among other matters.
All these reporting and monitoring need to be checked periodically, both by healthcare providers and health insurance companies that issue approved provider lists.
The healthcare provider credentialing process requires a lot of work. To clear the confusion, here you will know the basics of provider credentialing and we offer recommendations to complete it as professionally and excellently as possible.
What is Provider Credentialing in Healthcare?
Provider credentialing in healthcare is the procedure by which payers verify the credentials of healthcare providers to make sure they have the required licenses, certifications, and skills to properly see patients.
Credentialing by Other Names
Credentialing in the healthcare industry sometimes goes by other terms, including the following:
This is also known as getting on insurance panels, every health insurance company checks the credentials of a physician before it includes the provider/doctor/physician as an in-network provider.
The paperless term refers to software that accelerates the credentialing process, reducing or removing the need of paper to process.
Medical Sales Rep Credentialing
This is also known as vendor credentialing, it refers to healthcare organizations confirming on and monitoring the background and training of sales reps and other vendors who may want or need access to the facilities.
Credentialing is also used in non-medical contexts, including the following:
This is when an organization or group physician’s owner allocates credentials to its employees or vendors.
Political credentialing refers to political parties assigning credentials to delegates for party conventions.
Below are few entities listed those provide standards for Credentialing of Providers
The Centers for Medicare & Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations both want that healthcare providers be credentialed. Healthcare organizations that do not follow the CMS guidelines are not authorized for Medicare or Medicaid reimbursement.
Most of the US hospitals follow the Joint Commission accreditation, which is compulsory for Medicare and Medicaid reimbursement eligibility. Almost all states have their own regulations.
There are some other groups also have set standards on credentialing, and many healthcare organizations follow them to receive extra accreditation.
Following are those other groups:
- Utilization Review Accreditation Commission
- The National Committee for Quality Assurance
- Det Norske Veritas
- The Accreditation Association for Ambulatory Healthcare
Provider Credentialing Phases
The primary phases of provider credentialing are as follows:
- Healthcare payers require the provider information like their background, licenses, education, etc.
- In some cases, the healthcare payers work with a third-party company called a credentials verification organization (CVO) which works with the provider to collect and verify the information.
- In many cases, insurance companies do background checks. They directly correspond with medical schools and other organizations to verify the received information
- In some cases, the insurance company may use software to continuously check the information that licensing agencies and other organizations make available online
- Once the organization confirms all required details and find it suitable, the insurance company awards credentials to the provider
- Whenever insurance companies complete all the formalities, they can decide to approve the provider as an in-network provider. Once this is done, providers start receiving payments for the patients who have its insurance