Physician Credentialing and Privileges

Credentialing and Privileges

The staffing and credentialing process is critical, particularly because many health care practitioners rely on staff privileges and hospital credentialing to increase their patient pool through referrals. Rejections from hospitals and third-party payers can devastate a health care business and cause irreparable damage to a business’s reputation.

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Although state laws mandate minimum requirements to practice medicine, hospitals and third-parties frequently investigate health care providers before contracting or renewing working agreements with them. These hospitals and third-parties will search, collect, verify, and score a variety of performance factors for your health care practitioner or business. The impact of these credentialing procedures can result in damage to the practitioner’s current and future ability to practice medicine.

The staffing and credentialing process is critical, particularly because many health care practitioners rely on staff privileges and hospital credentialing to increase their patient pool through referrals. Rejections from hospitals and third-party payers can devastate a health care business and cause irreparable damage to a business’s reputation. Your business must prepare for these kinds of credentialing and privileging processes.

What is physician credentialing?

Credentialing is a formal process of verifying and assessing a physician’s education, training and experience.  The process ensures that patients receive the highest level of care from healthcare professionals who have undergone the most stringent scrutiny regarding their ability to practice medicine.

Credentialing can be very complex and time-consuming.  There are no currently centralized processes in place for credentialing physicians. This means you must create submissions to each entity and must be aware of the necessity of thorough recordkeeping to ensure that all information is completed, documented, and error-free.

What information or documents are required for credentialing?

Credentialing applications and the required documentation can be extensive.  Some important information and supporting documents that physicians should have ready include: 

  • Education, training, and board eligibility or certification
  • Work and medical staff history
  • Clinical privilege history
  • Names and emails of peers who can provide reference
  • Clinical report cards and performance reviews
  • Malpractice insurance carriers and any claims history
  • Explanations for any gaps of 30 days or more in education, training, or work history
  • Federal, state, and professional licenses and registrations

What does the credentialing process consist of?

There are three general parts to the credentialing process.  

  1. Credentialing (assessment and verification of qualifications)
  2. Privileging (provision of permissions to perform specific services at the institution)
  3. Enrollment (authorization to bill and be paid for the specific services)

However, the steps each organization may take can be different.  Typically the physician is required to complete the following steps: 

  • Credentialing application - each facility has its own application.
  • Supporting documents such as medical licenses and DEA ID number, malpractice insurance, board certification, education, work history, activity or log procedures and health documentation.
  • Verification of documents upon submission of the application.
  • Approval by the department heads and hospital boards.
  • Re-credentialing (if required) after the lapse of the initial privileges period.   

How long does a typical credentialing process take?

There are no set timeframes for credentialing.  Some facilities can finish the process in a few weeks, while others can take up to 180 days.  So, it is better to start the process as soon as possible and ensure that the credentialing application is properly and thoroughly completed.  

What are some of the problems associated with hospitals and third-parties credentialing or approving staff privileges? 

As discussed above, hospitals and third-parties who conduct credentialing and staff privilege look at many of the practitioner’s qualifications and documentations for verification.

Problems arise when qualified practitioners are denied hospital or staff privileges. Denials can be devastating for a health care business. Some physicians experience improper credentialing processes, while others are denied privileges based on prior conduct, disciplinary actions, or criminal history.  Reports of misconduct or disciplinary actions are also reportable to the National Practitioner Data Base (NPDB). Practitioners may be under an obligation to self-report disciplinary actions as disclosed to NPDB to their certification and licensing boards, which in turn can encumber their license to practice, depending on the nature of the disciplinary action. 

Loss of board certification may affect payer credentialing and loss of patients from that payer.  

Accordingly, issues with credentialing and privileges can cascade to much larger issues if they are not initially and properly addressed.

What is the National Practitioner Data Base (NPDB)?

The NPDB is a federal regulatory body that collects information on medical malpractice payments and other adverse actions related to healthcare practitioners, providers, and suppliers. In their effort to “improve healthcare quality, protect the public, and reduce health care fraud and abuse in the U.S.,” a report to the NPDB can result in severe negative consequences. Losing staff privileges, for example, can have a compounding, long-lasting impact on employment opportunities.

What can Perla do for my health care business?

Credentialing and privileges issues can arise at any time triggering a review process that can include immediate meetings and disclosures.  Physicians should consider engaging a healthcare attorney experienced in credentialing and privileges matters in their state to guide them through the process.  

Perla can instantly connect you with experienced healthcare attorneys in your state that can fight for you to get the best possible outcome.  Simply search the Perla attorney database for a healthcare attorney with healthcare regulatory and credentialing experience to find a list of qualified and vetted attorneys to advocate for you.

How to Find A Healthcare Attorney

You need a healthcare attorney who is experienced in your line of work and industry.  Because of the complex nature of health laws, healthcare attorneys are specialized in different niches and an attorney which specializes in federal payer reimbursement does not necessarily understand credentialing processes at local hospitals!

So, it is difficult to actually find a healthcare attorney that provides the exact services that you require in the type of practice that you have. In fact, you should consider using the Perla platform and services which will allow you and your healthcare business to find qualified experts and advisors with experience and knowledge in the healthcare industry, such as a healthcare attorney. 

Perla is a private networking platform that connects healthcare professionals and entities directly with expert advisors and consultants with experience in the healthcare industry. Get started in your FREE search today by visiting our website to find trusted experienced credentialing lawyers!

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