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  • Dilsa S. Bailey, CPMSM

The Four Phases of the Credentialing World



What is credentialing? In the healthcare industry, hospitals, managed care organizations, medical schools, and large group practices are just a few entity types that perform credentialing to determine if the healthcare providers affiliated with them are competent, qualified, and legally registered to practice. Credentialing sounds complicated, but it isn’t. Yes, there are a lot of steps entailed. Some of those steps have been mandated by state and federal guidelines as well as meet accreditation requirements. Some may be required strictly based upon the organization’s expectations. Though these steps may be interrelated and at times overlap the variety of mandates, the needs for each entity type differs. Here is what you would expect to be performed at the most popular kinds of healthcare organizations:​

1. Credentialing and Privileging – Hospitals

a. Verification and collection of data including applications, licenses, prescription registrations, education, training, board certifications, claims history, disciplinary actions, and more.

b. Documentation and ongoing oversight of what the provider can perform in a hospital setting, whether it’s diagnostic and treatment or surgical.

2. Credentialing – Managed Care Organizations

a. Verification and collection of data including applications, licenses, prescription registrations, education, training, board certifications, claims history, disciplinary actions, and more.

3. Provider Enrollment – Group Practices

a. Completing applications for hospital privileges, enrollment in managed care organizations, and the ability to participate in Medicaid and Medicare.

4. Pre-Employment – Faculty and Group Practices

a. Verifying and collecting data relevant to determine if the practitioner is a good fit for their organizations and if they would be eligible to apply to hospitals and managed care organizations for participation and reimbursement.

This description is a high-level perspective of the process that is labor intensive for all involved. The practitioners who are consistently required to provide information over and over, the entities that must track and credential each practitioner on a cyclical basis (hospitals every two years, managed care every 3, etc.). There is much to collect, review, discuss, and follow-up on. Why? To ensure that patient care is at the forefront. Every practitioner in every organization should be able to pass the test that answers one question. Are they qualified and competent?

That’s why credentialing is one of the most critical functions in healthcare organizations. Though I have mentioned four phases of credentialing for a few organizations, this function should not be bypassed for many other healthcare entity types, such as skilled nursing facilities, rehab centers, and more. If your organization falls into one of those categories, take a look at who should be looking at in your organization more closely.

Dilsa S. Bailey, CPMSM is the owner and principal consultant for The Right Credentials Network. If your credentialing and provider enrollment programs need assistance, contact The Right Credentials Network. We can help you apply for and maintain accreditation as well as repair your existing program. And, if you or your staff needs additional training, join us for our webinars, training modules, and various events.

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