What is Credentialing in Healthcare and Why is it Important?

While many may think of Medical Credentialing as a modern concept, it has been a part of physicians' careers since long before the middle ages. By the medieval period, the credentialing process was becoming more involved. In 13th century Paris, the formation of the College de Saint Come split the barber surgeons (surgeons of the long robe) from lay barbers (barbers of the short robe). To become a member of the College, and thus a surgeon of the long robe, one had to meet specific conditions for admission and pass an examination given by a panel of surgeons.

Modern day credentialing is far more complex and the process more error prone. We break down the basics of medical credentialing, the major players, benefits, best practices, most common issues and more. Read on to discover the convoluted, yet crucial, world of medical credentialing.

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Credentialing Process

What are the main components of Provider Credentialing?

The process may vary state-by-state, however, it usually involves three different processes:

1. Medical Credentialing

Provider credentialing is the process of verifying the qualifications and credentials of healthcare providers such as physicians, nurses, and other healthcare professionals to ensure they meet the standards and requirements set by insurance companies, hospitals, and other healthcare organizations. This process includes verification of education, training, licensure, work history, and professional references. The goal of credentialing is to ensure that healthcare providers are competent, qualified and have a good track record of providing quality care to patients.

 It must be completed upon the hire or enrollment of a new provider. It must be repeated regularly afterwards in accordance with the standards set forth by regulatory and accreditation organizations such as the National Committee for Quality Assurance (NCQA) and The Joint Commission (TJC).

2. Insurance Credentialing and Provider Enrollment

Insurance credentialing refers to the process of obtaining and maintaining insurance contracts with payers (e.g., insurance companies, Medicare and Medicaid programs) for the purpose of being reimbursed for services rendered to patients with insurance coverage through that payer. This process involves submitting information about the provider and their practice, and completing any necessary paperwork or online forms. The goal of insurance credentialing is to enable healthcare providers to participate in a payer's network, so they can receive payment for services rendered to patients with insurance coverage through that payer.

Provider enrollment, is a step in the overall insurance credentialing process and refers to the process of adding a healthcare provider to a payer's network of providers.  Provider enrollment involves submitting information about the provider and their practice, and completing any necessary paperwork or online forms.

There may be additional steps required by specific carriers. Many carriers use the Council for Affordable Quality Healthcare (CAQH) to source various credentialing information from a single trusted location. This means your carrier may require you to have a current CAQH profile as part of enrollment.

3. Privileging

In the context of credentialing, privileging refers to the process of granting specific clinical privileges to a healthcare provider based on their education, training, experience, and competence. The goal of privileging is to ensure that healthcare providers are qualified and capable of safely and effectively performing specific medical procedures or treatments, and to protect the safety and well-being of patients.

The privileging process typically involves a thorough evaluation of the provider's education, training, experience, and professional background, as well as any relevant clinical competency assessments. The healthcare organization or hospital will then make a determination of the specific clinical privileges that the provider is qualified to perform, such as performing a specific surgical procedure or administering a particular medication.

Privileging is an important component of the credentialing process, as it helps to ensure that healthcare providers are qualified to provide the highest quality care to patients. Healthcare organizations and hospitals typically have strict policies and procedures in place to govern the privileging process, and providers are expected to adhere to these policies to maintain their clinical privileges.

This information is consistent with the standards set forth by the National Committee for Quality Assurance (NCQA) and The Joint Commission, two well-respected organizations that accredit and certify healthcare organizations in the United States.

What does Medical Provider Credentialing involve?

Medical provider credentialing involves a review process of many different areas of the medical professional’s career, including but not limited to:

  • Career history
  • Education
  • Licensing
  • Residency
  • Specialty certifications
  • Qualifications

What Information is required for Credentialing?

Before signing up for the credentialing review, it is important to know what information is required from any medical professional wishing to complete the process. The following information is needed to fill out the Provider Application credentialing paperwork completely.

  • Personal Information
  • Education Information
  • Attestations (ensures forms are accurate and valid)
  • Current hospital privileges
  • Current work status
  • State of malpractice insurance
  • Work history

However, credentialing laws and regulations vary between states. Make sure to research any state-specific rules which may apply to the credentialing application process. To get more specific, the types of verification required for credentialing may include the following:

Personal information:

  • Citizenship information
  • Date of birth
  • Email address
  • Ethnicity
  • Gender
  • Mailing address
  • Name as written on license
  • Phone number
  • Previous names
  • Recent photo
  • Social security number

Education information

  • Attendance month and year
  • Certifications/degrees
  • Institutions (name and address for each)
  • Program director name

Work information

  • BNDD copy
  • CAQH password
  • CME documents
  • Current CV
  • Current state licenses copy
  • DEA copy
  • Hospital affiliations (past, present, pending)
  • Hospital privileges
  • Malpractice claims history
  • Peer references
  • Practice address
  • Practice specialty
  • Practice tax ID number
  • Practice phone number
  • Primary practice contact
  • Professional certificates (all current and past state licenses)
  • Professional liability insurance
    • Coverage amount
    • Current insurance copy
    • Expiration date
    • List of providers covered by policy
  • Provider NPI number
  • Work history

Major Players in Provider Credentialing

There are several organizations which handle the necessary information for primary credentialing. As aforementioned, each state has its own licensing program rules, often broken down further into those for doctors and those for nurses. The following are a few of those crucial organizations which handle credentialing information:

  • National Practitioner Data Bank (NPDB) – Contains information on license suspension, revocation or medical malpractice claims, allowing for verification of any negative events in the professional’s past
  • Federation of State Medical Boards (FSMB) – Contains compiled information on a medical professional, including certifications, education, states with active licenses and any negative instants from the past.

After applying, another set of massive players in provider credentialing are the U.S. health insurance companies.  Partnering with insurance companies is a necessary process for any medical office. Physicians and other professionals must provide a list of verifications to insurance carriers, including Medicare and Medicaid, in order to be eligible for reimbursable expenses.

Why Outsource Credentialing?

There are several reasons why providers may consider outsourcing their credentialing process:

  1. Time savings: The credentialing process can be time-consuming and complex, involving numerous forms and applications, as well as the collection and verification of a large amount of information. By outsourcing this process, providers can save time and focus on delivering patient care.

  2. Increased accuracy: Credentialing outsourcing companies have specialized knowledge and expertise in the field of credentialing, and can help ensure that the process is completed accurately and efficiently. This can reduce the risk of errors and help providers avoid costly mistakes.

  3. Improved compliance: Outsourcing companies are often up-to-date with the latest regulatory requirements and can help ensure that providers are in compliance with all necessary regulations and standards.

  4. Better efficiency: Outsourcing companies have streamlined processes in place to handle credentialing tasks and can often complete the process more quickly and efficiently than providers can on their own.

  5. Cost savings: Outsourcing the credentialing process can save providers money by reducing the need for in-house staffing and resources. In addition, outsourcing companies often have established relationships with insurance companies and other stakeholders, which can speed up the process and reduce administrative costs.

Overall, outsourcing the credentialing process can provide numerous benefits to providers, including increased efficiency, cost savings, and improved accuracy and compliance. By partnering with a reputable outsourcing company, providers can focus on delivering quality patient care, while leaving the credentialing process in the hands of experienced professionals.

How long does the Medical Credentialing Process take?

It can take anywhere from 90 to 150 days, depending on the state requirements. Due to the extended processing time, make sure to leave plenty of time – at least four months -- to complete the credentialing application process.

Best Practices to Streamline the Physician Credentialing Process

As mentioned, the physician credentialing process can take quite a long time, even more so for medical professionals who are not adequately prepared. Streamline the process with these five best practices.

1. Stay Current

Staying current with relevant organizations, like the Council for Affordable Quality Healthcare (CAQH) can make things a little simpler. According to an article published by Physicians Practice, “most payers in the nation have adopted [the CAQH] program.” The piece also notes that both new and veteran physicians who update their CAQH regularly find both credentialing and re-credentialing easier.

2. Prepare Credentialing Packet

Credentialing  can be difficult to complete correctly, not to mention stressful. Provide potential staff with the information and tools which would not only make their application process easier but also let them know you support their efforts (see below).

3. Start as Early as Possible

Have medical staff start the application process as soon as possible. Credentialing can take upward of four months so have medical staff start the process at least four months before their expected work start date, if possible. An article by Physicians Practice notes that “as payers have merged and supersized, a practice’s ability to…expedite an application has shrunk,” which means that you need to give yourself ample time to get through the application process.

4. Contingent Start for new Providers

In order to avoid having a new provider not yet credentialed, have their start date tied to their credentialing paperwork submission date. For instance, have them start no sooner than four months after the submit.  As a Physicians Practice article notes, “it’s better for the practice in the short run: it isn’t scheduling around payers with which the new physician is not credentialed. And it’s better for the new physician, whose schedule can be filled sooner and practice grow faster.”

5. Keep Tabs on the Process

because the process is often so convoluted, it is ideal to keep all medical staff members’ application status info in one place, for easy reference and updating. This allows for any readjustments to be made in order to comply with the application processing.

Medical Credentialing Packet Checklist

Filling out all the application forms can be daunting. To make the application process more transparent for them, consider including the following in a Medical Credentialing Packet:

  • A completed W9 form
  • A list of insurance companies to apply with, including links to online applications
  • Instructions on how to apply for National Provider Identifier (NPI) and CAQH numbers
  • National Provider Identifer-2 (NPI-2)
  • Practice info: address, phone, fax number
  • Taxpayer Identification Number (TIN)

Helping medical staff or candidates with the process, by providing the right tools and information to make the journey smoother, will both support and help them to complete the process.

Most Common Issues in Provider Credentialing

Of course, readying and completing the application is just one of the steps in the entire process. It also needs to be checked extensively for any errors. The following are some common errors seen with Credentialing:

Missing details

This includes any missing supporting documentation, required training or filling in of education or work gaps.

Incomplete application

This includes any part of the application which was not completed, including blank areas, missing support documentation and incorrect info.

Incomplete training

This occurs when some institutions require further postgraduate training or a completion of residency for credentialing criteria, but the applicant has not fulfilled the request.

Poor organization

 A lack of organization can cost an office in appeals and lost reimbursements. Instead, consider outsourcing the credentialing process to a professional such as RevenueXL in order to keep the office on schedule and ensure no credentialing expiries occur.

Government compliance

There may be more credentialing requirements depending on which state your practice is in. Make sure to check for reciprocity agreements with the state and payer organizations when taking on a physician from another state.

Timing trouble

Many offices aim for the minimum credentialing process time. However, many payers actually take much longer, around five to six months. To be extra sure, plan for the longer processing time while hoping for the minimum.

Re-credentialing: Who, What, When, Why and How

What: Re-credentialing requires a provider to repeat the credentialing process.

How: Providers will get a letter notifying them they are up for re-credentialing.

Why: Re-credentialing allows for a physician’s skills and history to be constantly reevaluated, hopefully minimizing any continuing to practice poorly.

When: If providers don’t complete their re-credentialing within the deadline, their credentials are suspended until the process is completed and approved. During that period of suspension, they may not practice medicine.

Who: For example, boards often require re-credentialing every three years, according to state or federal requirements.

Medical Credentialing and Physician Credentialing FAQs

Q: Credentialing seems like a hassle. Why is credentialing and privileging important?

A: It absolutely matters. Medical credentialing and privileging is how states and insurance agencies vet providers and decide if they are a high-quality medical provider or not. This, in turn, trickles to the patient, who wants their insurance to cover their costs, which is only possible through medical credentialing.

Q: How do I get credentialed with insurance companies?

A: To get insurance credentialed, go through the medical credentialing application process. Insurance companies will not work with someone who does not first have their medical credentials.

Q: What happens if a staff member’s application is not yet approved?

A: If someone works who does not have their credentials, then insurance carriers will not reimburse them. Insurance carriers do not reimburse medical offices that bills for services or professionals who have not been properly credentialed.

Q: I don’t know how to do credentialing for physicians. Who knows how to do medical credentialing?

A: RevenueXL offers medical credentialing services. We know the ins and outs of physician credentialing companies and can assist any professional on their medical credential journey.

For further information on how RevenueXL can assist with medical credentialing needs, please do not hesitate to contact us at (888) 461-9998. We look forward to answering any and all of your medical credentialing questions.


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