Credentialing and Privileges

In the realm of healthcare, the process known as hospital credentialing plays a crucial role in verifying the qualifications of medical providers to ensure the delivery of safe and high-quality medical services. While this process can be resource-intensive and time-consuming, it stands as a legal requirement that underpins patient safety and quality care within healthcare settings. Moreover, effective hospital credentialing not only safeguards patients but also offers protection to healthcare providers and institutions.

It’s essential to distinguish between credentialing and privileging, two terms often used interchangeably. Hospital credentialing, the initial step, entails verifying the qualifications of a provider, while privileging follows, granting the provider the authority to practice medicine within a specific healthcare facility.

Getting It Done

Before physicians can commence their services, their credentials undergo thorough verification to confirm their competence and legal eligibility to practice. During hospital credentialing, providers are required to submit detailed information encompassing their education, work experience, licensure, medical training, insurance coverage, and background. This information is meticulously scrutinized to ensure accuracy, authenticity, currency, and good standing.

The hospital credentialing process varies across institutions, yet it invariably necessitates specific documentation. This usually includes many the following:

• state licenses
• certification statuses
• surgical logs
• documentation of hospital privileges
• insurance claims reports
• updated resumes
• certifications in medical procedures like ACLS/BLS, DEA certificates
• immunization records
• educational diplomas
• professional references
• residency certifications
• personal identification documents

Additionally, credentialing may encompass background checks and sanction verifications conducted by regulatory bodies such as the Office of Inspector General (OIG), typically involving direct communication with primary sources and cross-referencing records for consistency.

Upon successful verification of documentation, the applicant’s files are reviewed by an executive committee within the hospital. This committee may engage in discussions with the applicant and relevant stakeholders before approving the application and forwarding the information to regulatory bodies like the Joint Commission for further scrutiny.

Getting to Work

Once hospital credentials are secured, physicians may be granted privileges to practice within the healthcare facility. These privileges are categorized into three types: active or admitting, courtesy, and surgical, each delineating specific scopes of practice within the hospital environment.

Telehealth credentialing presents unique challenges, particularly for smaller healthcare facilities and practitioners. The conventional credentialing and privileging process can pose significant barriers to telehealth patients’ access to care, exacerbated during emergencies such as the ongoing pandemic. To expedite credentialing, practitioners may opt for “credentialing by proxy,” a method allowing them to practice at distant sites under the oversight of associated originating sites like hospitals.

While the Centers for Medicare and Medicaid Services (CMS) have introduced measures like credentialing waivers during crises, adherence to specific regulations remains paramount. Key requirements for credentialing by proxy include signed agreements, valid licensure, evidence of privileges at distant sites, and certification of distant sites as Medicare or telehealth facilities. Additionally, ongoing performance reviews and complaint sharing between originating and distant sites are crucial for regulatory compliance.

Despite its significance, the hospital credentialing process often encounters delays due to common roadblocks. These include missing or incomplete information on applications, varying state regulations, and misconceptions regarding credentialing responsibilities among healthcare organizations. Addressing these challenges requires thoroughness in application submissions, awareness of state-specific regulations, and clarity regarding organizational responsibilities.

We Can Help

In response to the complexities of hospital credentialing, credentialing assistance services like Red House offer solutions to streamline the process. By providing end-to-end credentialing support, primary source verification, continuous monitoring, and background checks, Red House helps healthcare institutions save time and resources while ensuring compliance with credentialing standards and enhancing patient safety.

If you’d like help managing your hospital’s credentialing and privileging processes, digital management, or to build an internally managed offshore team, reach out to schedule time with the team at Red House.