The importance of compliance in credentialing

In our ongoing series, we had a close look at Credentialing and what it entails. We also gained insight into how healthcare companies and providers manage this very important function in healthcare recruitment. Having understood why healthcare credential management is so crucial not only from a business perspective but also ensures there are no legal implications, the stage is just right to introduce another factor closely related to Credentialing, namely Compliance.


Join me in exploring why Compliance in Credentialing is so important and how this need not be such an onerous task with specialized apps, customized specifically for online healthcare recruitments. Credential compliance is achievable with minimal stress. Let us understand how, but first-a brief background.


I am using the the term ‘Compliance’ to mean meeting the requirements for Credentialing and participating in effective Compliance programs as set forth by the Office of Inspector General (OIG) and the National Committee for Quality Assurance(NCQA). This includes internal auditing, monitoring, credentialing education and training, developing plans of corrective action in responding to related problems as well as enforcing credentialing standards. Most Compliance programs, while generally operating as independent entities, report to their respective boards of directors or other committees providing assistance and oversight to the process.

So, what happens if a healthcare fails to verify accurately? Without careful oversight and auditing, it is all too possible for omissions or errors to occur before, during, or immediately following the process, which could lead to enrollment issues as well as open a pandora’s box to legal problems if the process is incomplete or the provider’s privacy is compromised. Furthermore, the 1960s case of Darling vs. Charleston Hospital established the responsibility of hospitals and other healthcare facilities in verifying the professional credentials of the physicians and other providers practicing under their roof.

Organizations that fail to fully verify a prospective candidate’s credentials before hiring and allowing a candidate to practice are running the risk of incurring serious legal and financial consequences for themselves as well as the physician/ provider. I am sure you are already privy to some of them but for starters, there are lost revenues as insurance carriers will not reimburse for services by uncredentialed practitioners. A newly graduated candidate seeking to join a carrier’s plan, including Medicare and Medicaid, needs to be approved by each separate plan. He or she should be advised to submit a provider-enrollment packet specific to that carrier, including the required credentials as soon as possible when considering an employment opportunity.


Some of the forms of verification usually include, but may not be limited to, the following:

  • Proof of education and additional training
  • State license
  • DEA license Board certification
  • Hospital affiliation
  • Provider enrollment application

Whilst the obvious benefits of careful credentialing are avoidance of legal and financial pitfalls, most importantly, it ensures that patient care is in safe hands and their recovery is managed by medical staff who have verified credentials.


At this juncture, it would be useful to highlight the role of Joint Commission, one of the largest independent, not for profit organizations, which accredits and certifies more than 21,000 healthcare organizations and programs in the United States. Joint commission surveyors visit accredited healthcare organizations once every 39 months to evaluate standards in compliance. These visits or surveys are normally conducted unannounced. The surveys are managed by highly trained experts who work in the healthcare industry themselves–doctors, hospital administrators, nurses and other healthcare professionals. The surveys are fairly detailed, and they can pick up random health records to make observations about how the care is being managed. Apart from verifying credential compliance of healthcare staff on duty, they also engage in discussions and interactions with patients, doctors and nurses. The Joint Commission standards focus primarily on safety and quality of care. The reports are made public for all Joint Commission accredited and certified health care organizations

Automating and eliminating the mundane aspects of recruiting and credentialing and enabling both staff and candidates to access real time data and information facilitates a healthy relationship between yourself, your client and their candidates. Happy customers are all good news for your business and employees. Everybody wins!

Does it all sound overwhelming? If so, how can you ensure this critical aspect of healthcare compliance in credentialing can be managed with the least amount of stress and with absolute accuracy?

Wouldn’t it be wonderful if you could have a magic wand to ensure you are hiring the right candidates, ensuring their credentials match with the requirements and yet make the whole process absolutely smooth and hassle free without all the tedium? How about an end to end solution, fully integrated and customized to your business need or recruitment specifications which addresses all the pain points we spoke about in our earlier articles. A few clicks and all the recruitment processes right from posting, tracking, scoring, credentialing & scheduling are managed from a single platform.


We are as excited to share as you are excited to know! Stay tuned!

 About TargetRecruit: With a globally-connected presence, TargetRecruit’s creative and innovative solutions have helped healthcare companies like AMN & Medpro manage their recruiting, staffing and sales operations. Targetrecruit featured on the INC 5000 2016  list of the most successful and fastest growing businesses in America. In October 2016, Gartner listed TargetRecruit in their Market Guide For Service Procurement Solutions.


Other parts of Credentialing series

How Healthcare Companies Manage Credentialing

Credentialing and Its Importance in Healthcare Staffing

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