Credentialing Corner

# What is Involved in Physician Credentialing

- July 18, 2023
- Posted by Kristen Edwards

18 Jul

Physician credentialing is a complicated process aiming at maintaining the standards of health care providers to the patients. It is the process of checking and validating the personal and as well as professional records of the physician, including but not limited to their educational records, qualifications, certificates, and licenses. All new physicians entering a healthcare facility are subjected to this process before permitting them to start work there.

However, it is not a one-time process, as physicians already working in the institute also need to go through it after a lapse of a few years. Today, we will look at the importance of this step in maintaining the quality standards of the healthcare facility. We will provide you with the ultimate physician credentialing checklist to ensure your application is up to the mark and ready to be accepted.

## Why is Credentialing Important?

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Every new physician has to go through this process when they plan to work in a healthcare facility. Physicians who have already undergone this process must also get themselves re-credentialed every 2-3 years. So why the need to go through this long and arduous process? Here are some points explaining its importance:

### 1. Quality Assurance

Physician credentialing ensures that the doctors being chosen for the job are up to the mark in every respect. It ensures that the doctors meet all the healthcare facility’s experience, skills, and education standards. All the certifications, licenses, and credentials the doctor provides are verified before selecting them for the job so that only the best ones come on board to deliver quality healthcare to patients.

### 2. Patient Safety and Effective Treatment

The credentialing process ensures that the doctors chosen for the job meet all patient safety standards and can provide the best care possible to people in need. It ensures that the doctors have gone through a rigorous evaluation process based on quality standards. This allows the facility to deliver the best healthcare possible to its patients and reduces the risk of negligence or malpractice.

### 3. Legal Compliance

The state legally binds all healthcare facilities to get their physicians credentialed. This applies to all the new physicians coming to join the facility as well as the old ones. Regulatory bodies governing these facilities regularly check these credentials. To make sure that the healthcare institute is complying with all the requirements of the regulatory bodies as well as the legal codes of the state, it must have a credentialing process in place for its doctors and healthcare providers.

### 4. Reputation

Credentialing process ensures that the doctors are fit for the job in every respect. Physicians who have gone through this process have trust in their practice and can demonstrate that they are willing to undergo the evaluation process to maintain their standards. This creates a reputation for the doctor and allows others to trust the doctor to give them their best in times of need.

### 5. Insurance Coverage

Many insurance companies reimburse the insurance amounts only if the physicians meet the conditions for credentialing applications and have gone through the credentialing process. Credentialing ensures that the physicians taking the insurance reimbursements meet the quality standards of the insurance company and can provide the service bills on time. This allows physicians to take timely payments for their work and services without hiccups.

## Physician Credentialing Checklist – The Documents

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The documents needed with the credentialing application can vary with institutions, but some of the most important ones that many a physician credentialing checklist includes are:

- Personal info like name, DOBs, addresses, emails, and phone numbers.
- Social Security numbers and cards
- Photographs (often signed and dated)
- Medicaid and Medicare numbers
- Copies of National Provider Identifier Number (NPI) documentation and confirmation letters
- UPON numbers
- Federal tax ID numbers
- Resident cards, green cards, or visas for foreigners
- Up to date Curriculum Vitae (having your complete professional history and work experience with starting and ending dates)
- License of medical practice
- Practice address (if any)
- Contact number of the practice facility
- Insurance details of practice
- CAQH IDs
- PECOS IDs
- State Controlled Substance Registrations Or Certificates
- Educational qualifications (with the time of starting and completion, name of the facility, program directors,
- Copies of the Board Certificate (including the dates of issue and the board name)
- ECFMG certificate number and info on Fifth Pathway (for foreign graduates)
- Hospital affiliation details
- Currently, active state licenses
- Malpractice history (if any)
- Details of any disciplinary action
- Professional Liability Insurance Coverage details, preferably of the last ten years
- Peer reference documents and recommendations with contact details of the institute/personnel and addresses
- Completed Delineation of Privileges Form
- Case logs of the last two years (if any)
- ACLS/BLS certification
- DEA certificate
- Mammo numbers and MQSA (if applicable).
- Military discharge record -Form DD-214 (if applicable).
- Copies of USMLE, FLEX, NBME, or SPEX scores
- Copies of Any: APLS, ATLS, BLS, PALS, NRP, or ACLS certificate(s)

## Physician Credentialing Process

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Physician credentialing checklists and the important points to consider on these checklists vary from state to state. The rules and regulations involved in the process and the total time it takes for the credentialing process to complete are also different in different regions.

The entire process can take a minimum of three months and a max of five. However, depending on the accuracy of the physician’s data in his application and the validity of their references, the process may also get prolonged.

The essential points to consider in the whole process are as follows:

### 1. Pre-Application

This is optional in many institutions’ credentialing processes, but some do ask the doctors to submit a pre-application before submitting their official conditioning data. This process is done to rule out any non-serious doctors applying for the job and engage only those who are serious about not only their time and that of the institution but also about getting a good position and a steady job opportunity.

The pre-application covers only some basic data about the doctor, such as:

- Criminal records
- Record of any disciplinary action taken against them
- Certifications from various boards and regulatory authorities

Most doctors applying for the credentialing process are clear in all these respects, and so will you, hopefully. But if any issues are found in these credentials, the doctors are asked to submit their explanations on the issue at hand. This is not a very big matter of concern, as any doctor with a clean record can explain any issue, whether big or small. But the downside is that a small amount of time will be spent.

### 2. The Actual Credentialing Application

Once the board has cleared your pre-application, you can get the go-ahead to prepare the official credentialing application. You must attach all your personal and professional data with this application, so it will be a good idea to get your degrees, certificates, and work documents in order.

### 3. Submission of Documents

Once you have completed the application and collected the required documents, you can submit the application to the healthcare facility of your choice, such as a hospital, clinic, or any other credential-verifying authority. Make sure to double-check your application and the documents before submitting them to prevent any errors or mishaps on your part.

### 4. Receipt

Once you have submitted the final application, it is advisable to follow up with a phone call or an email to the institution to verify the receipt of your application by the institute and the review process. Many institutes often provide emails about the updates in the review process, but in case you don’t get such updates, it will be a good practice to contact them yourself.

Sometimes, you may be asked to provide additional data during the review process. In these cases, it is advisable to provide all data promptly to avoid any delays in the application processing. Unnecessary delays might hamper the review and lead to a waste of your time and the institute’s.

### 5. Verification Process

The credentialing authority verifies your application and the documents and credentials you provide by contacting medical schools, hospitals, training bodies, and licensing boards. The body may also contact any references you might have given to confirm the accuracy of your credentials. The physician is not usually involved in this process, so you can sit back and wait for the process to get completed.

### 6. Approval or Denial

Once the review and verification process is complete, the credentialing body decides if the physician is credible to work in the facility. If they approve, they contact the physician and grant them the go-ahead to start working in the facility. If they deny the application, they might give some reasons explaining their denial.

### 7. Agreement Signing and Further Documentation

Once the physician gets the privilege to work in the facility, they are usually asked to sign various agreements and complete any further documentation the facility may have. These documents usually contain the terms and conditions for working at the facility, renewal details, and compliance documents to any organizational policies.

Due to the process’s complex and time-consuming nature, many healthcare institutes begin the credentialing process several months before hiring any new physician to work with them. For physicians already working in the facility, the authorities provide timely notices several months prior to the expiry of the credentialing application to give them adequate time to complete their applications and other relative data.

Many institutes are shifting the process to online and digital platforms to speed up the process. The physicians have to put the data into the system through their computers or mobile phones, and the system automatically cross-checks the data using a centralized command and checking system. This saves the facility and the physician a lot of time as any manual filling or handling of the application is prevented, expediting the whole process.

## Conclusion

Physician credentialing is an important, albeit complex, process that allows healthcare facilities to check the eligibility and professionalism of the physicians applying for new jobs and maintain the quality standards of the doctors already working in the facility. It ensures that the facility is only choosing the physicians who are the best fit to provide quality care and treatment to the patients. The credentialing application requires the physicians to provide a complete set of several documents relating to their educational qualifications, work experience, professional certificates, and training credentials. We have provided you with the complete physician credentialing checklist covering all the necessary documents. Make sure to go through the checklist with heed to ensure that your documents are in order and that your application and review process can go smoothly.

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