The Reasons why Medical Credentialing is key in Delivering Safe Healthcare Services

The Reasons why Medical Credentialing is key in Delivering Safe Healthcare Services

The goal is to live a happy and healthy life but falling sick to an illness or getting injured is part of life. Many of us go through acute illnesses while some experience chronic ailments. But in both cases, we must get proper treatment to regain health.

The acute diseases are for a short duration and are easily cured by taking certain medications, but it is the chronic ailment that can be prolonged for months, and the patient has to take constant medication and even undergo a surgical procedure in most cases. The treatment of chronic disease such as heart issues, stroke, and cancer is quite expensive and cannot be managed without a person having a health insurance plan.

The Key Elements of Healthcare System:

Effective and efficient health facilities for a particular illness, injury, or physical and mental disorder are given by healthcare providers that include doctors, surgeons, physicians, nurses, clinical psychologist, therapists, and social workers. A robust healthcare system involves constant identification, diagnosis, treatment, recovery, and prevention of diseases.

The role of the healthcare provider is quite crucial as wrong diagnosis can not only endanger the lives of the patients but raise a serious question on not only the credentials of the healthcare workers but the authenticity and capability of the medical practice as well.

The medical field is quite vast, and for a person to deliver proper treatment to the patient, he/she must be qualified in a particular aspect of healthcare that includes medicine, psychology, nursing, dentistry, and physiotherapy. A medical practice or hospital is a place where numerous healthcare providers perform their pertinent duty in giving timely treatment and care to the patients.

For cost-effectiveness and ensuring sustained quality improvement, the healthcare system must not only integrate advanced technology in the medical field but also find qualified and skilled professionals who can provide the necessary medical services to the patients. A hospital must implement modern software solutions that can help in streamlining not only the provision of services but also the revenue cycle with timely and correct claim processing and payment collection.

One of the toughest tasks for a medical practice is to find and recruit the right candidate that can easily carry out the required task in an efficient manner. The hospital with demanding and increasing workload mostly tend to outsource the recruiting program to firms that specialize in providing qualified and trained staff to health organizations.

Why Medical Practice needs to hire Qualified Healthcare Providers:


When a patient comes to a hospital or clinic for either diagnosis or treatment of his illness, he/she is putting trust and depending on the healthcare provider to ensure full recovery or cure from the disease. In common ailments, diagnosis and treatment are fairly simple, but it is complex for complicated and critical chronic diseases.

Medical credentialing is one of the important factors in the healthcare system that is growing significantly. Medical credentialing is the name given to the process of meticulously examining the credentials and qualification of a healthcare provider that includes his/her

  • Education
  • Career History
  • Training
  • Residency and Licenses; and
  • Specialty certificates

Credentialing is crucial to make sure that the most qualified and certified professionals are recruited as the care of patients is of utmost importance. The healthcare providers consist of a team of professionals who not only have to communicate effectively but also have respect for each other and ensure the confidentiality of the patient. Apart from the professionals, there is also a group of the young medical staff that includes trainees and residents who should get proper guidelines from the experienced staff, so the standard of the healthcare system is maintained.

Learn more Key Information of Medical Credentialing

From a medical practice perspective, hiring incompetent healthcare providers with unfulfilled medical qualifications can be quite problematic and increase the chances of malpractice cases if patients are not treated properly. Credentialing is the key process that ensures that a hospital system, surgical center, or any other health care center does not suffer from any bad reputation and impending legal proceedings.

The Significance of Medical Credentialing:


Medical credentialing involves verifying the qualification, skills, training, experience, and ability of the healthcare provider, whether the individual is a physician, surgeon, lab technician, or nurse. The education, training, and license is a testament that the individual can provide a particular medical procedure or service. Many of the medical practices, mostly in populated urban cities, face a constant stream of patients and more so amid the Coronavirus pandemic where not only the medical staff but the administrative staff is under immense pressure.

The importance of medical credentialing has increased in recent times due to

  • Compliance rules and standardization of accrediting bodies
  • The requirements of third party payers
  • The expansion of the medical field and the need of healthcare practitioners in those fields

The best solution for hospitals is to employ the services of professional companies that offer not only staffing but also credentialing services. PETTIGREW is a one-stop solution that offers diverse medical solutions such as medical billing and coding, healthcare consultancy, staffing, and credentialing for hospitals and other health centers.

The first step is to communicate with the primary sources mentioned on the resume of the applicant or practicing doctor to authenticate the qualifications directly. A Credential Verification Organization (CVO) contacts the university or any other institution from where the provider received the formal education or training. Today a robust web-based software is used to reduce time and eliminate any fraudulent documents.

Credentialing is used not only by hospitals but also by insurance companies that can allow a qualified and trained individual to become part of the healthcare system. It was in the 1990s when the National Committee for Quality Assurance (NCQA) defined specific policies and guidelines on the process of medical credentialing.

The regulations and rules ensure that a stringent method is applied, and every aspiring healthcare provider is scrutinized in the right manner based on his/her education and training and how to deliver quality healthcare to the patients. Every day numerous patients come in for treatment of various ailments, and each patient feels relieved to see that the healthcare provider is a thorough professional, and all his/her qualifications and skills are verified and certified.

The Reasons to Devise Proper Medical Credentialing method:

The credentialing process boost competition among the healthcare providers who also keep their colleagues in high regard based on their knowledge and skill. In today’s testing time, when health centers are overburdened with work and treatment of Covid-19 patients, improper credentialing can directly impact the revenue cycles and health insurance. The healthcare providers could not be timely reimbursed, and more importantly, it can result in compliance violations, monetary damages, and legal proceedings due to medical malpractice.

PETTIGREW has developed suitable and valuable solutions and systems regarding staffing, credentialing, coding and billing solutions that has allowed medical practices to streamline their services. The administrative staff is trained professionally according to approved guidelines that remove any issues regarding claim processing and payment collection.

PETTIGREW medical business services can reduce the on-hold claims, standardize the administration and recruitment process, and save effort and time needed in compliance. The medical credentialing process should be completed before the healthcare provider is allowed to work and provide patient care. Medical credentialing is a two-step process

  1. Pre-application process
  2. Reexamination and re-credentialing or renewal of healthcare providers licenses after every two years

It is the sole responsibility of the hospital to ensure that the records of all the healthcare practitioners are in order and properly maintained. The medical credentialing process is directly linked with accreditation standards and required under federal and state laws.

Medical credentialing is also linked with reimbursement, which ensures a smooth medical revenue cycle management and allows the medical practice to sustain financially. A medical practice should devise and define proper evaluation methods to monitor the performance of the healthcare provider from initial work appointment to later years of employment.

How Healthcare Providers Benefit from Medical Credentialing:

One essential aspect of medical credentialing is ‘Provider Enrollment,’ where the healthcare providers request to join or participate in a health insurance network. Provider credentialing is where the doctors and physicians are linked with the payers, and patients get to use their insurance plan. In contrast, provider enrollment ensures that health practitioners get full reimbursement of their medical services which is very important as they shouldn’t be the ones at loss in any case.

The provider enrollment is a process where a provider requests, contracts, and enrolls a plan. The healthcare provider has to fill

  • Credentialing/enrollment application
  • Submit copies of training, and corresponding licenses
  • Signed contracts and other documents

PETTIGREW offers medical credentialing and starts the process by first evaluating the top payers in the area and by reviewing the needs of the medical practice. Once initial work is done, then a contract is drafted for the work to be done, and payment is made. The necessary documents from the healthcare providers are collected, and the insurance company is called to start the application process. Due to advancements in technology, most of the applications are filled and submitted online. After submission, there are timely follow-ups done to the payers, and a date is given on which the contract begins, and the healthcare provider can submit and receive claims.

PETTIGREW can help represent the providers and help with reimbursement that can help a medical practice to improve its revenue cycle management in medical billing. Medical credentialing is a time consuming and challenging task that is now made easy by a modern software solution that will automate the entire credentialing process and ensure timely provider enrollment. The software has advanced features such as clinical documentation improvement solutions where alerts and reminders can be made on maintaining the documents and tracking expiration dates on medical licenses.

Medical credentialing is one process where a patient can wholeheartedly put confidence in a particular medical practice. It is a standard process where data is collected and sent for primary source verification and committee revenue by respective healthcare agencies to ensure the merit and experience of the provider.

According to statistics, deaths due to medical errors are rising each year, which compels the medical practices to use enhanced solutions to verify the capability and skill of the healthcare provider. Paperwork is always tedious, and one mistake in credentialing can cause long term issues such as a physician giving care with an expired license or a nurse giving services beyond her qualifications and training.

The medical practice keeps its focus mostly at the time of hire, and regular monitoring is neglected, which can put the life of the patient at danger, the physician may be asked to take early retirement from practice, and reflect a bad reputation of the health center. Outsourcing medical credentialing tasks can remove errors, ensure validation and verification is done within days instead of weeks and months, reduce considerable costs, and guarantee safe and reliable healthcare services to the patients.
Contact PETTIGREW today and schedule a free consultation with one of expert to help you with your medical billing and credentialing needs!