Credentialing in healthcare refers to the systematic procedure for ensuring that a healthcare practitioner meets the required standards of competence before the facility grants any kind of clinical privileges or professional credentialing. This enables organizations to make sound decisions based on verifiable documentation rather than just an application or CV.

For health care facilities, credentialing involves compliance, readiness, payment and care of patients. The specifics may vary depending on facility, providers, payers and regulations, but an organized approach can help streamline requirements and support decision-making.

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Credentialing is not a one-time paperwork exercise. It is an ongoing cycle of collecting, verifying, reviewing, approving, monitoring, and renewing provider information.

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What Is Healthcare Credentialing?

Credentialing is the verification process that establishes the education, training, licensing, experience, professional background, and qualifications that are pertinent to the role of the healthcare provider. Credentialing could be done for various purposes depending on the environment such as appointing the medical staff, granting privileges, etc.

Why credentialing matters

• Patient safety Ensures review of qualifications and professional background prior to the delegation of clinical duties.
• Compliance Provides a written process for adhering to organizational, accreditation, payment, and regulatory requirements.
• Reimbursement readiness Assures the accuracy of the provider data prior to the utilization of such information by the payers.
• Operational consistency Ensures consistent requirements, review process, documentation of approvals, and renewal procedures.

Where credentialing came from

Credentialing arose from hospital medical staff bylaws, where credentials were first reviewed before allowing doctors to admit and treat patients. Each group that came after, from accrediting agencies to government-sponsored programs and even managed care plans, set their own credentialing requirements, and more paperwork followed. Credentialing is today considered an essential business process by most organizations since a single oversight in credentialing could delay everything from hiring to billing and scheduling.

Who needs to be credentialed

The quick answer is virtually any clinician that provides treatment to a patient, bills an insurance company, or maintains privileges in a hospital or institution regardless of whether the provider is an employee or not. The specific list varies depending on state, payer requirements, accreditation organization, and the hospital itself.

• Physicians and Surgeons — Such professionals generally get the most intensive examination involving issues such as certification, affiliation with hospitals, and history of malpractice in all states where they have worked.
• Nurse practitioners, physician assistants, and nurse midwives — should have their own license verification, along with the verifying physician's license if required by state law.
• Therapists, social workers, dietitians, and others like them — Allied health care practitioners tend to contract with insurers individually, so it's important to find out who will cover whom.
• Counseling and psychologists — Behavioral health practitioners possess licenses that vary from state to state, and as such, the license held must correspond with the services that they provide within a certain contract.
• Telehealth and locum tenens physicians — Whether a doctor treats patients from another state or fills a temporary opening, they still require verification of credentials prior to the initial patient interaction.