Most provider and payer organizations have large teams of credentialing professionals whose full-time job is to fully evaluate an individual’s education, training, and work history to ensure that he or she can meet the standards required to be granted practice privileges and be paid for rendering high-quality and safe medical care.
Credentialing is an important process in two main venues: hospitals or other provider organizations, where medical staff credentialing occurs, and the healthcare marketplace, where third-party payers determine whether practitioners hold the proper credentials to be paid for delivering medical services. Although medical staff and payer credentialing involve very similar processes, they also differ somewhat, especially relative to the granting of privileges to perform certain activities. These privileges primarily fall under the purview of an organization’s medical staff.
While interrelated, credentialing and licensing are separate processes that serve different purposes and are performed by separate private and public organizations.
PRACTITIONERS
Credentialing usually involves licensed medical practitioners, who can include physicians (i.e., medical doctors, doctors of osteopathy, or others with degrees who have been licensed by the state to practice medicine), dentists, clinical psychologists, podiatrists, and other providers as determined by the organization responsible for the credentialing process.
Recent years have seen a growth in the licensing and credentialing of advanced practice nurses (i.e., nurse practitioners) and physician assistants. For credentialers, this increase has become a major undertaking because these types of providers work, in most states, under the direct supervision of a licensed physician. Instead of the responsibility to maintain the credentials of one professional, the work increases exponentially with the additional licensed professionals.
RISK AND LIABILITY
Underlying the credentialing process is the desire to protect the public from those who do not have adequate education, training, and experience or the demonstrated competency to deliver high-quality, safe healthcare services. Unfortunately, several widely publicized cases have been reported of extremely dangerous, even homicidal, physicians who were able to succeed repetitively in passing through the credentialing process until caught. Perhaps even more disturbing than these high-profile cases, however, are the many practitioners who are now credentialed to practice medicine but are doing so unsafely or with poor quality standards.
A thorough and systematic approach to the credentialing process that uses industry-wide best practices and standards should help prevent or mitigate the validation problem. Also, providers themselves, especially physicians, need to take their obligation seriously both to hold themselves to the highest standards and to hold their peers to the same standards.
Physicians and other providers must work tirelessly to ensure that those who are incompetent are removed from the system. This task is not easy, nor should the responsibility for policing provider competencies strictly rest with organizations, such as the organized medical staff’s credentialing committee.
Nevertheless, no group is better equipped to assess another’s capabilities than the professional peers of the provider in question. Practitioners need to take the responsibility very seriously to hold their fellow professionals accountable and set standards for the industry that ensure that the utmost priorities are high-quality care and patient safety.
The governing board of most hospitals and healthcare systems has the ultimate responsibility of ensuring that medical staff credentialing is done appropriately. The responsibility for verification standards cannot be simply delegated to the medical staff. Increasingly, lay board members realize that they must become familiar with credentialing regulations, standards, policies, and procedures.
While most board members are financially protected through directors’ and officers’ insurance from personal liability for inadequate credentialing activities, this protection does not extend to regulatory sanctions that might be brought against an organization whose board members are not adequately overseeing the credentialing process.
AUTOMATION OF CREDENTIALING PROCESSES
Credentialing is a time-consuming, laborious task that is often perceived by key stakeholders to take far too long to perform. Automated tools, therefore, are available to speed this process along and to accelerate some of the credentialing steps. However, that automation is only appropriate for certain noncritical credentialing tasks, and human resources must still make sure that items such as primary source verification are done thoroughly and appropriately.
POLICIES AND PROCEDURES
Best practices should be codified in the individual organizations and followed consistently. Variability from written procedures undermines high-quality credentialing activities and can lead to serious harm events in the patient care arena. Furthermore, and as mentioned, many credentialing processes require seemingly unacceptable lengths of time to properly perform. Nevertheless, certain steps in the process should not be subjected to shortcuts. Most high-performing credentialing offices are adequately staffed and equipped to handle the workload in a high-quality fashion that does not overly prolong the process.
GOING FORWARD
Finally, credentialing is a dynamic process, and new requirements and further development of best practices will require all credentialing professionals continuously to update and expand their knowledge.