What are Credentials and why is it so crucial in Healthcare Staffing. Let us take a look at Credentialing. What it means, what the process entails and the significant and crucial role Credentialing plays in Healthcare management.

In today’s litigious society, even the smallest medical misstep can cost hundreds of thousands in legal and medical costs. Hospitals, physician practices and other health organizations are increasingly targets of lawsuits, especially when the problems are the result of failure to fully verify the professional credentials of the practitioners and others on their staffs. For smaller practices, this is an especially difficult position, as staffing, time and other limitations can increase the chances of failing to perform a thorough check of a new associate’s background.

CREDENTIALING DEFINED

In the 1960s, the Darling v. Charleston Community Memorial Hospital case established the obligation of hospitals to verify their physician and other provider competencies. This landmark suit soon resulted in the creation of the Credentialing process as hospitals and other organizations sought to protect themselves from similar lawsuits.

Credentialing is commonly defined as the process of examining, reviewing and verifying that a candidate’s professional licenses or certifications, education, experience and other variables are in order and all occupational and related criteria are met. The term is also used with medical groups’ closed panels to determine the eligibility of a prospective provider for clinical privileges at a hospital or managed care organization (MCO). In what appears as a straightforward process, Credentialing can be a difficult and often confusing practice, since many healthcare practitioners require different types of education and certifications.

WHY ARE CREDENTIALS OR CREDENTIALING IMPORTANT TO THE HEALTHCARE INDUSTRY?

Healthcare credential management is an important and essential function for hospitals and others which precedes hiring or obtaining coverage by an insurance carrier. It might seem like credentialing is just a paperwork task, mundane and not as important as patient care, but it’s a task with priority that cannot be taken lightly. It not only protects an organization from potential lawsuits, it’s also a way to ensure practitioners are qualified to do the job they’re being hired for. It’s a safeguard put in place to protect patients by providing qualified, high-quality health care providers.

Credentialing not only protects an organization from potential lawsuit, it’s also a way to ensure practitioners are qualified to do the job they’re being hired for. It’s a safeguard put in place to protect patients by providing qualified, high-quality health care providers.

Credentialing is not to be confused with ‘network contracting’ or ‘enrollment’ although it is necessary for insurance companies to also verify professional Credentials before adding a new physician or other provider to the organization’s or group’s coverage. Many provider networks and other carriers utilize the  services of CAQH to acquire credentialing data from a centralized location and therefore require that their participating providers have a complete updated  profile on file in the system. Hospitals, managed care organizations as well as individual practices and healthcare staffing companies must perform strict Credentialing due to the possibility of a malpractice lawsuit against a staff member as well as against the hiring organization.

HOW ARE CREDENTIALS OR CREDENTIALING INFORMATION OBTAINED AND VERIFIED?

When determining the credentials of a candidate, it is necessary to contact the primary source: the medical school that granted the degree(s), the government and professional organizations that conferred certification or licensing, as well as verify practice history and related employment.

While the medical staff of hospitals and most healthcare organizations have authority to evaluate (and recommend corrective or disciplinary action) the membership status and clinical privileges of participating medical professionals, most hospitals and MCOs have formed their own credentialing committees, which are usually made up of physicians, physician assistants, nurses, and other healthcare providers.

Much information about providers is stored in centralized data sites such as the National Practitioner Data Bank, an information clearinghouse opened in 1990 and designed to streamline the information-gathering process for credentialing committees and others who need to verify this kind of information.

WHAT ROLE DOES THE JOINT COMMISSION PLAY IN CREDENTIALING?

The data bank makes the process of verifying credentials easier for the person or committee responsible for collecting Credentialing data, but it’s the Joint Commission, an independent, non-profit organization, that audits hospitals and other healthcare organizations to ensure that practitioners not only follow best practices, but also meet specific standards that ensure safe and effective healthcare. The Joint Commission uses credentialing data when deciding if a healthcare organization will be accredited.

Without proper Credentialing processes, an organization risks losing accreditation through the Joint Commission. During an audit of the Joint Commission, improper credentialing can come to the surface, a misstep I mentioned earlier. Without solid documentation of a practitioner’s credentials, it’s sure to cause problems, even litigation.

HOW CAN I IMPROVE CREDENTIALING IN MY OWN BUSINESS?

Now that you have a basic understanding of the Credentialing process and why it exists, how does the process affect your organization? Is credentialing something that your company struggles with? Have you come across incidents where insufficient credentialing created an unfortunate situation? Share your stories with us! We’ve worked with several prominent healthcare organizations to help guide their Credentialing processes by streamlining and automating the processes, bringing in time and cost efficiencies.

As healthcare evolved from solo practices to super specialty set ups, the Credentialing process simultaneously developed in complexity making healthcare credential management an onerous task.

In our next blog on the Credentialing series, we explore some of the methodologies and processes companies employ to fulfill their credentialing obligations. Stay tuned.

TargetRecruit has provided healthcare staffing solutions across the globe. Learn how to we can help you with Credentialing tasks during the recruiting and hiring process.

After all, wouldn’t you rather focus your energy on patient care or your clients?