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One Size Doesn’t Fit All Credentialing Programs

Yes, some standards should be met. There are credentialing requirements dependent on your corner of the healthcare industry that must be fulfilled. Hospitals and managed care organizations have a different set of accreditation criteria. Each state may have another set of standards or an unusual twist on the general norms required. What you may consider being an elementary set of rules for all healthcare organizations may need a second look to ensure your compliance. You not only will need to consider the verification and collection of the most common provider data, but you will want to take a moment to determine what your state is mandating. Don’t think for a moment that credentialing is a simple process and that all the items in the state, CMS, and accreditation checklists are the same. They are usually not.

One of the things I do as a consultant is to write credentialing or medical staff policies and procedures. I build foundations for those programs. But, before I write a single word, I research not only the latest accreditation requirements for the healthcare entity type, I look very carefully at the state requirements, especially state requirements overseeing health insurance products such as Medicaid. And, of course, Medicare Advantage criteria is an included consideration. After all these years though, I don’t think I have never ceased to be surprised by at least one or two state regulations. Those regulations can be all over the place. I have seen states require health plans to collect CME’s and CEU’s. I have encountered states that have required single credentialing cycles so convoluted they make it difficult to go into delegation arrangements. So, what does that all mean? No two states are the same, and truly no two credentialing programs are the same, even in the same state.

Whether the overall goal of your credentialing program is to meet accreditation, CMS, or your state regulations, there are always two things I advise you to keep in mind, relevant and current knowledge of the requirements and seamless operational flow. Implementing the best credentialing program that fits your organization specifically is the only thing that matters. Don’t be afraid to step outside of the box to make sure your program fits your organization’s needs.

Dilsa S. Bailey, CPMSM is the owner and principal consultant for The Right Credentials Network. If you are interested in maintaining or applying for NCQA Credentialing Accreditation or CVO Certification, contact her for more information. Dilsa helps to build and repair credentialing programs and trains staff to perform efficiently and productively.

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