Hospital Medical Staff Credentialing | Complete Guide

Touseef Riaz

August 1, 2022

credentialing requirements

Hospital staff credentialing, also known as healthcare credentialing, is a crucial process for the healthcare practice. This is a process of verifying that the healthcare provider and medical staff are properly trained and certified to perform the services. Medical credentialing helps in maintaining high-quality safety standards in the healthcare practice/facility. Legally, medical credentialing is an essential process for the safety and quality care of patients. This process also verifies the credentials of healthcare physicians and professionals.

hospital medical staff credentialing

What is credentialing in healthcare?

Healthcare credentialing comprises two parts; credentialing and privileging. Credentialing includes verification of professionals’ credentials and their competency as demonstrated via their:

  • Education
  • Professional experience
  • Training
  • Licensing
  • Certifications

However, the process of granting healthcare professionals approvals/authorization based on their expertise to perform procedures is known as privilege.

Importance of Healthcare Credentialing

Why is credentialing important in healthcare? To process insurance claims, facilities need to verify the proper credentials of the healthcare provider(s). One major benefit of proper medical credentialing is that it prevents the admission of rogue or incompetent healthcare workers. This ensures that patients are receiving the best quality and safe care at the healthcare facility. Medical credentialing verifies:

  • The applicant is who they demonstrate to be
  • The applicant holds a current license
  • The applicant is fully competent
  • The applicant is not in violation of any laws

Here are the top three reasons why healthcare credentialing is important

1. It starts with quality patient care

Providing quality and safe patient care is the primary goal of any healthcare organization. This is why credentialing the medical staff and verifying their data is extremely important.

2. Helps prevents healthcare providers from revenue loss

Healthcare providers are in partnership with various insurance carriers. For getting or receiving reimbursements from the insurance payers, healthcare providers are required to be medically credentialed. It ensures that any doctor or nurse on board with the practice is capable and competent to provide the medical services. Various insurance payers may ask for credentialing after a period of time. However, the requirements for documents may change from time to time.

Failing to provide the required documentation and not being compliant may not be tolerated by the insurance payers. Therefore, insurance payers can withhold the funds/reimbursements, and the healthcare practice risks losing thousands of revenues.

3. Increases professionalism and efficiency in the hiring process

By providing the required documentation and credentials, the healthcare practice demonstrates professionalism. Credentialed healthcare providers are considered professionals in the industry. In the era of advanced technology, healthcare providers can easily use medical billing and credentialing software for doctors’ credentials and verify them. Using automated tools is way better than the old ways of credentialing. 

Moreover, credentialing is also an efficient tool for hiring healthcare practitioners. This process verifies a healthcare provider’s qualifications, experiences, licenses, and certifications. Therefore, validating the competency of a medical professional. After doing so (verifying and credentialing), insurance providers will issue a contract. Various healthcare organizations use medical credentialing and this data to hire any healthcare practitioners. However, going through all the data is way easier with medical credentialing software.

4. Improves patient’s trust in the healthcare organization

For a healthcare practice, their patient’s trust in them is a huge deal. The healing process of a patient is highly affected by their state of mind. This is why patients’ trust in their physician is important; without trust, they won’t open up to the physician. And without proper and complete information regarding a patient’s condition, how can a doctor provide treatment?

However, with medical credentialing, the patient knows about the qualification of their doctors. Therefore, increasing trust and confidence between the two. And with trust, patients are more likely to follow the doctor’s orders, diet plans, and any changes in medication properly.

5. Reduces the risk of errors in healthcare services

There are a huge number of deaths due to medical errors every year. Medical practitioners and healthcare providers have a great responsibility to provide safe and quality patient care. And to reduce the risk of any medical errors, the first step would be medical credentialing. This process verifies and validates the certifications, qualifications, and licensing of the healthcare practitioners. Therefore, determining the safety and quality of patient care. There are several medical billing credentialing automation systems for verifying the qualifications, therefore, eliminating ambiguity. Automation in medical credentialing also reduces the risk of any human errors and hence improves the quality of healthcare services. 

6. The Reputation of healthcare practitioners

The reputation of healthcare providers and medical practitioners enhances due to credentialing. Moreover, a good reputation also provides the patients with a good reference. Patients search the healthcare practitioners’ information beforehand due to the concerns like poor diagnosis & treatment. This is why medical credentialing is essential; it increases trust and confidence among the patients as well as enhances the reputation of the practice.

Yes, medical credentialing does take the time and effort of the provider, but once it is done, there is no limit to how many patients are covered.

7. Lesser cost

In medical billing, credentialing is quite a cost saver. Medical credentialing can be pretty time-consuming and may distract physicians from providing safe and quality patient care. With increased competition, healthcare providers are shifting towards automating their processes and streamlining their workflows. And with everything going on at such a high pace, paperwork and manual entry is simply a waste of time. Therefore, automating the entire process saves them time and money and lets them focus on providing quality patient care.

Hospital Credentialing Process

Requirements for credentialing depend on the state. For accepting Medicare and Medicaid, ensuring the guidelines of two federal agencies are followed by the credentialing department. Medical credentialing is a time-consuming task; however, it needs to be done on time and properly.

Following are the steps crucial for the hospital credentialing process:

1. Identify and gather the required documents

First and foremost, knowing what documentation the insurer requires is necessary. Even a single missing piece of documentation or form can delay the entire process. Each insurer has different requirements; therefore, make sure proper documentation and forms are being submitted.

Start by making a list of the insurance carriers you are reaching out to, then make a list of all the documents required. The documents for medical credentialing requirements include the following (but are not limited to it):

  • Name
  • Social security number
  • Demographic information
  • Education information
  • Residency details
  • Career history
  • Proof of licensure
  • Gender
  • Citizenship, language, and ethnicity
  • Specialties and patient focus
  • Claim history
  • Proof of insurance
  • Information about your healthcare facility

2. Prioritize the insurance providers

Make a list of insurers you want to submit the application first to, as you’ll need to submit it to several different insurers. If most of your medical billing is going through a single insurer, then start by submitting your credentialing application to them. For credentialing, you need to be familiar with the regulations of every insurer so you can make a better decision.

So, make a list of insurers you want to reach first and categorize the rest priority-wise. Based on this, assemble the documents as required by each insurer.

3. Check/Verify the accurate information

The quality and accuracy of the documentation and information being provided are the keys to medical credentialing. This is why, when assembling the required documents for credentialing, ensure the following steps before submitting the application:

A background check must be conducted

Verify the educational history, and reputation through healthcare organization, licensing, and board certification. The healthcare organizations include:

The American Medical Association (AMA)

ECFMG – Educational Commission for Foreign Medical Graduates Certification 

The American Board of Medical Specialties.

If any sanctions are recorded by the OIG, list them all. 

Be aware of all the errors as they can cause delays in the process, errors for instance:

  • Inaccurate months and dates of the employment
  • Incorrect contact details of past employers or references
  • In case of a past malpractice omission, the claim can be disqualified.

After organizing and verifying all the documents, prepare them to be presented to the leadership. Now when it comes to verification, there can be two ways of doing that; manual or other options.

1. Manual Verification

Manual verification, as the name suggests, is the old-fashioned way of verifying the information for medical credentialing. It involves emailing and calling key organizations like the American Medical Association (AMA), other key organizations, and the medical school.

And for obvious reasons, manual verification can be quite time-consuming and result in further delaying the process.

2. Other methods of verifying

Other ways of verifying are advanced option, which involves either using credentialing software or outsourcing the process.

a ) Credentialing software

There are various software(s) out there that can automate the entire process of verifying by cross-referring the profile (resume & application) with:

  • The American Medical Association (AMA)
  • Medical schools
  • The OIG – Office of Inspector General
  •  Any other key organizations

b ) Outsourcing medical credentialing

Outsourcing has become quite common and proven beneficial for healthcare organizations. If your administrative department is facing any work overload, outsourcing the credentialing process can save their time and potentially money.

4. Complete the CAQH enrolment

Applying for medical credentialing through CAQH (Council for Affordable Quality Healthcare) is a requirement of several insurers. This is alongside completing the individual application of credentialing. Note that incomplete and inaccurate information can result in delays.

UControl Billing’s medical credentialing services cover the CAQH enrollment for you, so you don’t have to.

5. Wait to receive the verification

After all the steps mentioned earlier are completed and submitted to the insurer, the waiting game begins! Now waiting for approval from the credentialing organizations can be a time-taking process.

6. Follow-up

In case you don’t receive any response, don’t just keep waiting! Follow-up on your application; in case more information is required, gather the documents, verify and submit them.

What is re-credentialing?

Recredentialing is a periodic process of verifying the healthcare provider, physicians, or doctors’ credentials. This process involves verifying and screening the education, credentials, and training of the medical service providers.

On hiring, the healthcare physician or provider must be credentialed; however, re-credentialing should be done after two years (in most states).

What if credentialing isn’t approved by the credentialing committee?

In case the credentialing committee doesn’t approve or deny the provider’s application, they will be notified. This notification is a written notice comprising of reasons behind the denial as well as data sources. Healthcare providers have the privilege to appeal the denial. However, the appeal should be made within 30 days after re-credentialling (in writing). 

Outsourcing Medical Credentialing Services

Medical credentialing in medical billing and re-credentialing can be very time-consuming. It requires a lot of work and follow-ups. However, outsourcing the entire process can result in several benefits for your practice. On top of all, it minimizes errors and provides advanced and high-tech solutions.

Reasons to outsource medical credentialling

Following are the top five reasons to outsource medical credentialing services:

  1. Lesser human resources required
  2. Less expensive
  3. Improved efficiency
  4. Lesser workload and paperwork
  5. Increased security
  6. Faster turnaround

Medical Credentialing Services at UControl Billing

Our Medical Credentialing Services include:

  • Credentialing specializing in all the states
  • Data Gathering & CAQH Enrollment
  • Application Submission & Payer Communication
  • Medicare Revalidations & Yearly Maintenance
  • Re-Credentialing and Demographic Updates

Frequently Asked Questions (FAQs)

1. What is the process followed when is medical staff credentialing?

Requirements for credentialing depend on the state. For credentialing, you need to be familiar with the regulation of every insurer so you can make a better decision. Process of medical credentialing includes:

  • Identifying and gathering the documents
  • Prioritizing insurers
  • Verifying information
  • CAQH enrollment
  • Submitting the application
  • Waiting & Follow-up 

2. What is the process of credentialing?

Hospital staff credentialing, also known as healthcare credentialing, is a crucial process in healthcare practice. This is a process of verifying that the healthcare provider and medical staff are properly trained and certified to perform the services. It helps in maintaining high-quality safety standards in the healthcare practice. 

3. How long is the credentialing process?

It takes up to 90 to 120 days for a standard credentialing process, based on the guidelines. However, it can take more time based on the complexities.

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