What Is Provider Credentialing and Why Is It Important?

Provider credentialing is critical for patient health and safety, but it can be a lengthy process with many challenges along the way. Learn the necessary steps for credentialing and the best ways to make the process more efficient.

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Provider credentialing is the process a healthcare organization goes through to make sure its providers have the required qualifications and skills to do their jobs. The process can be lengthy, with many challenges and headaches along the way, but it is necessary to safeguard the health and safety of patients.

Here are the basics of credentialing, along with tips to make the process more efficient.

What is provider credentialing?

Provider credentialing involves verifying and evaluating the qualifications of healthcare providers, such as physicians, nurses, therapists, and other clinical staff. Credentialing ensures providers have the necessary education, training, licenses, certifications, and other qualifications to perform their duties safely and effectively.

Who’s responsible for credentialing?

Credentialing typically is done by healthcare organizations — such as hospitals, clinics, and health plans — to confirm all providers they work with meet specific standards. Their education and training, licensure and certification, work history, malpractice history, background checks, reference checks, and interviews with the provider are all part of the process.

Why credentialing is important

Credentialing cultivates trust among stakeholders, including patients, healthcare providers, and insurance companies. Patients can feel confident their healthcare providers are qualified and competent, while providers and insurance companies can trust their colleagues and affiliates meet high standards.

Besides promoting trust, credentialing is vital for patient health and safety. By confirming providers have the necessary credentials, healthcare organizations can reduce the risk of medical errors, malpractice, and other adverse events. Credentialing also helps to make sure providers are up to date with the latest knowledge and techniques in their field, which can lead to better patient outcomes.

What are the steps involved in credentialing?

The credentialing process can be complex and time-consuming, involving multiple steps and stakeholders. Below are the typical steps for credentialing a provider:

  • Learn your state’s credentialing requirements. It’s best to check the state DHS website to verify.
  • Gather all requested documents, such as education and training records, licensing and certification information, work history, and malpractice history.
  • Contact educational institutions, licensing boards, and previous employers to confirm the accuracy of the provided information.
  • Complete the Council for Affordable Quality Healthcare (CAQH) application (if applicable).

Once you’ve finished the process and submitted all appropriate documents, receiving accreditation can take several weeks. You may need to follow up on the process’ status. After the credential is acquired, the provider must ensure their current status and perform any necessary tasks to maintain their credentials, such as ongoing education.

What are credentialing best practices?

Healthcare organizations must streamline the credentialing process by finding ways to speed up the process without sacrificing quality. Here are some best practices to consider:

  • Start early to avoid delays; credentialing takes longer than you think.
  • Provide and verify accurate information.
  • Designate a credentialing coordinator.
  • Automate the process by using online credentialing software or platforms.
  • Outsource to an experienced third party to free up your staff to focus on other tasks.

Stay equipped in healthcare credentialing

Credentialing is increasingly critical among providers. Make sure you have a system for staying up to date on changing standards and practices and can track, monitor, and act on gaps in credentialing among personnel. Whether this means setting up in-house systems for compliance or outsourcing the task to an established partner, what matters is everyone on your staff is well equipped to do their job to the best of their abilities within the parameters expected of them.

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