The Importance of Credentialing

The Importance of Credentialing

Credentialing is the first process in onboarding a physician with a facility. It is an assurance that the applicant is who they say they are. Are the credentials they have provided legitimate? Do they meet the requirements to be on staff at your facility? The process includes verifying information such as:

  • Education and training
  • Residency
  • Licenses
  • Specialty certificates
  • Qualifications
  • Career history

The provider is responsible for getting the required information to the person who will be overseeing the process. In most healthcare organizations, this will be a designated credentialing expert, such as a medical staff coordinator for larger facilities, or a practice manager or business office manager for smaller facilities and private practices.

One of the biggest challenges with credentialing is when applicants do not provide the required information initially. When the credentialing expert receives partial, incomplete, or missing information, the process becomes more time consuming.

PETTIGREW makes the process more streamlined by using credentialing software to help with this process by archiving information, so the provider only has to give it once regardless of how many times it’s needed for credentialing, privileging, or payer enrollment. However, the provider is still responsible for submitting complete information, and the credentialing expert is responsible for keeping it organized so the process can move forward.

Privileging and payer enrollment

In addition to credentialing, a provider may also need to go through privileging and payer enrollment. The differences between these processes can be confusing, and sometimes it’s assumed that once one of the three steps has been met when the physician has begun the process. At the basic level the three processes for Credentialing and privileging are:

  • Credentialing: Generally, refers to primary source credentialing (background check), also known as primary source verification.
  • Privileging: Making sure the provider has the appropriate training and experience to meet the minimum requirements and all authorizations to carry out requested procedures at a specific facility.
  • Payer enrollment: The process by which a medical provider gets entered into insurance plans, networks, Medicare, and Medicaid, so the provider and facility can be paid for services rendered to patients by that provider.

Background checks

A crucial step in the credentialing process that can’t be overlooked is a background check — even if the applicant’s CV looks impeccable. The three most frequently used data banks for background checks on healthcare providers are:

  • National Practitioner Data Bank (NPDB)
  • The Board Action Data Bank of the Federation of State Medical Boards (FSMB)
  • America Medical Association Physician Masterfile (AMA)

Background checks help protect your patients from incompetent medical practitioners and will reveal any negative sanctions taken against specific physicians. It’s an important way to make sure you’ve done your due diligence, since some physicians fail to include this critical information in their applications.

Credentialing Tools

For many facilities, credentialing is a manual process, which can be time-consuming and is often prone to errors and redundancies. However, credentialing software tools can help reduce errors, eliminate redundancy, and speed up the credentialing process. They can also help organizations ensure providers remain compliant, so they can continue to practice and be billable. For example, automated alerts can notify the medical staff coordinator or HR director that a license needs to be renewed by a certain date.

Software tools can also improve visibility into the credentialing process, making it easier to check on progress and spot potential risks that could prevent a provider from going to work.

PETTIGREW professionals have vast experience providing Credentialing and Contracting to Practices/Groups, Providers, Ambulatory Surgery Centers, Federally Qualified Healthcare Centers, Hospitalists, and ER providers.

In addition to working on enrollments in nearly 50 states, we also understand that each state has different requirements when it comes to credentialing and
Payer Connect is used as a secure, HIPAA compliant solution to ensure the credentialing process by using multiple safeguards to make sure all necessary documentation is accounted for from start to finish through a standardized process involving data collection and primary source verification, our clients and their patients are assured of their healthcare professionals credentials.

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