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Provider credentialing is essential. Healthcare organizations must have bylaws in place that define medical credentialing requirements to remain in compliance and ensure the providers have the qualifications they claim to have.
The credentialing process involves gathering large amounts of information and documentation from the provider and verifying it. Then, your organization checks with various organizations to ensure those credentials are valid and current.
Verification includes background checks, employment verifications, exclusion screenings, and other checks.
Completing the process correctly is key to finding qualified providers. It ensures they can provide the kind of high-quality care your patients expect.
Explore our provider credentialing checklist to improve your processes.
Table of Contents
- What Is Provider Credentialing?
- How Provider Credentialing Works
- Our Credentialing and Background Screening Tips
- How Healthcare Background Check Services Streamline the Process
What Is Provider Credentialing?
Healthcare provider credentialing is a structured process used to verify that a provider has the qualifications and credentials to perform the job. It's a vetting process that confirms the provider can legally and competently perform the job duties.
Credentialing is often detailed and complex to ensure the person meets requirements set by accrediting bodies, third-party payors, and other stakeholders. All credentialing must be completed before a provider can start working at a healthcare organization.
Which Qualifications Need Verification?
A provider credentialing checklist typically includes a wide range of qualifications for the position. The specific qualifications vary based on the type of medical position and the specialty of the provider.
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- Common qualifications verified during credentialing include:
- Educational background, including a medical degree and specialty training
- Continuing education
- State or national licensure
- Board certifications
- Criminal background check
- Work history, internships, fellowships, and experience
- Malpractice claims
- Hospital privileges
- Insurance coverage
Why Is It Important?
Provider credentialing ensures the individual has the skills and competencies to handle the position and deliver quality patient care. It's imperative for patient safety and your organization's reputation.
Proper credentials are required to maintain regulatory compliance, which helps you avoid fines or legal consequences for employing an unqualified person. You also need to hire properly credentialed employees to ensure you receive insurance reimbursements without issue.
Examples of Provider Credentialing
Looking at examples of provider credentialing can help you better understand the process.
- Primary source verification: This process involves going to the issuing organization to verify the credential's validity. For example, you might contact an educational institution to verify a degree or the licensing board that approved a healthcare license.
- Hospital privileges: You may need to verify qualifications for a provider to have privileges at a particular hospital so they can perform procedures at that facility.
- Health insurance credentialing: Before a provider can receive reimbursement from a health insurance company, they must undergo a credentialing process that ensures they have the correct qualifications.
How Provider Credentialing Works
The provider credentialing process may vary based on the organization and the purpose of credentialing. However, many of the steps are similar regardless of the purpose.
What Steps Are Involved?
Several steps are involved in provider credentialing, including:
- Establishing requirements: Determine the qualifications providers must have for the role. This helps you decide which qualifications you need to verify.
- Gathering information: The provider gives you the necessary information to help you run your verifications. They also need to provide documentation, such as an application form, a copy of their CV, and supporting documents, including licenses and diplomas.
- Verification: You must verify the validity of all the claims and documentation provided by the individual to ensure its accuracy. This step typically includes a background check.
- Clarification: If you can't verify something or you're missing information, contact the individual for clarification. They may need to correct the details or provide more evidence.
- Credentialing decision: Once you verify all the information, you can decide whether the person meets the qualifications.
What Documents Do Employers Need to Collect?
Employers need to collect supporting documentation to ensure the provider meets the minimum qualification requirements. Some examples of documentation to include in your provider credentialing checklist include:
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- Driver's license
- Social Security card
- Verification of citizenship
- Licenses
- Diplomas
- Training certificates
- Work history
- Certificate of insurance coverage
- National Provider Identifier documentation
- Curriculum vitae
- Work logs
How Can Employers Minimize Credentialing and Verification Delays?
Provider credentialing can take anywhere from 30 days to 6 months to complete. Starting as soon as possible minimizes delays.
Providing thorough instructions gives applicants the information they need to complete the application accurately. Lack of information or incorrect completion could slow down the process.
It's also helpful to communicate clearly, respectfully, and promptly with all involved parties. This ensures everyone has the correct information and understands the urgency of the situation.
How Does Provider Credentialing Help Reduce Liability Risks for Our Organization?
State and federal regulations require credentialing to ensure compliance and verify the provider's qualifications. You lower potential financial liabilities due to noncompliance by having strict credentialing processes in place.
Checking qualifications also ensures the provider knows how to perform the essential tasks of the job safely. This increases the quality of patient care and reduces the risks of malpractice cases for your organization due to harm caused by an unqualified provider.
Our Provider Credentialing and Background Screening Tips
It's crucial for your healthcare organization to have provider credentialing processes in place. The following tips improve your results to ensure you're hiring the best providers.
Start the Verification Process Early
It can take months to verify all a provider's credentials, and the process must be completed before the individual begins working at your facility.
Starting the verification process early helps to streamline the process and allow time for additional information gathering, when necessary.
Check Exclusion Lists
Looking for a provider’s name on exclusion lists can save you time. If the provider appears on an exclusion list, they're prohibited from providing patient care if your organization received funds from federal programs, such as Medicare and Medicaid.
Exclusion and sanction monitoring could eliminate providers early in the credentialing process if you rely on funding from federal programs. It's not worth your time to check their other credentials if the exclusion would disqualify them for the position.
Document Your Findings
Documentation is essential for compliance and backing up your decisions. You're required to complete provider credentialing to meet regulations, and your documentation proves that you followed those steps.
If you must withdraw a job offer due to issues that arise during credentialing, you have evidence that supports this decision. This information may be necessary if the provider accuses you of unfair treatment or tries to challenge the decision.
The documentation can also become a part of the individual’s file if they pass the credentialing process. If a performance issue arises in the future, you can look back at that documentation to show due diligence.
Track Progress and Completion Dates
Because it's a lengthy process, it's helpful to track your progress. Having a provider credentialing checklist makes it easier to keep track of where you are in the process.
Include checkboxes to show that a task was completed. You can also add completion dates for each step to monitor the efficiency of your process and have a record of when a step was completed.
Know the Relevant Regulations
Regulatory agencies determine what type of information you need to verify before a new provider starts working with patients. Failing to follow those regulations could result in financial or legal repercussions for your organization.
Ensure you know the required processes for the position based on those regulations, such as compliance for background checks. Keep current on any changes to the requirements to determine if you need to update your credentialing processes.
Communicate Proactively
Effective and consistent communication can help the credentialing process go smoothly. Letting the provider know what they need to provide prevents delays and ensures you get the information you need to complete the process efficiently.
You also need to communicate well with other organizations as you contact them to verify the person's credentials. Research the proper contact channels to save time.
Use Reliable Background Screening and Verification Services
Several software programs and services are available to help with background screening and credential verification. Choosing the right program is essential.
Background screening programs, such as PreCheck, follow industry regulations and help you maintain compliance. You also get reliable results in one comprehensive dashboard where you can collect all relevant information about your employees.
PreCheck also offers other services, including immunization tracking and healthcare license monitoring, allowing you to monitor your employees with one central dashboard.
How Healthcare Background Check Services Streamline the Process
Conducting screenings and verifications manually is a time-consuming task that can delay the hiring process for healthcare professionals. PreCheck and other similar background check services automate many of the processes, providing accurate results for all types of checks, including student background checks and drug and occupational health testing.
Programs designed specifically for healthcare offer targeted search options and provide the details you need to meet healthcare regulations. These programs save you time and money while helping you avoid problems, such as issues with background check compliance in healthcare.
Choose PreCheck to Screen Your Providers
Thorough provider credentialing protects your organization from compliance issues and increases the quality of care you provide to patients. PreCheck simplifies the process and helps you complete your provider credentialing checklist efficiently.
Contact one of our PreCheck experts for a demo and to learn more about how it can support your credentialing process.
Author: Brent Gibbons
Bio: Healthcare Screening Expert at Cisive PreCheck.
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