What is Physician Credentialing?
Hospitals, physician offices, managed care insurance companies, and laboratories all credential physicians. Credentialing is the act of gathering information about a doctor or medical provider to ascertain their qualifications to practice medicine in their given specialty.
There are several agencies that oversee the credentialing processes. The Utilization Review Accreditation Commission (URAC) is considered the leading agency that monitors the credential and qualification standards in health care. Medical providers must go through a credentialing process before they are hired by medical facilities and insurance companies. Physician credentialing, sometimes referred to as medical credentialing, will verify education, licensure, training, quality, and overall ethical standing of the provider in the medical community.
The doctor’s credential process begins with the medical provider submitting information to the credentialing agency for review. Areas of focus include:
•Education – verify medical school and any post-graduate training
•Board Certification – specialty certification and training
•Licenses – where doctor holds licenses
•Background Check – any criminal history is researched
•Malpractice Claims – checking for any malpractice claims and/or awards
•Malpractice Insurance – ensuring appropriate levels of insurance available
•Federation of State Medical Board review
•Privileges -hospitals where physician practices
•Resume detailing work history
The information is gathered and reviewed by a physician peer-review committee. These committees make recommendations as to the professionalism and standing of the provider within the medical community. The committees will often evaluate the ethical behavior of the medical provider.
Insurance companies, including government-sponsored payers, will research the medical credentials of a physician before accepting her or him into their group of participating providers. Medicare and Medicaid will not allow physicians who have not gone through their credential procedures to bill for services. Managed care organizations also have a strict physician credentialing process before a provider can be listed as participated with the insurance company. Many private physician practices also credential their doctors to ensure quality delivery of care.
Provider credentialing is a way of assuring consumers that medical providers have been reviewed by their peers. It provides a higher level of trust and guarantee that the provider is licensed and Board Certified and has not had licenses or privileges revoked in any other state. It cannot, however, determine the quality of delivery of care by the provider. Most credential committees have policies that providers have to participate in periodic credential updates and reviews in order to keep their status current.
There are companies, such a medical practice consultants, that specialize in provider credentials. The companies consult with medical facilities and/or provider practices to monitor and ensure that physicians’ credentials remains current.