Hospital Credentialing 101

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.

Red House Launches BPO

BPO Launch

Red House is announcing the launch of Red House Services, a business process outsourcer, run by an experienced team of globally-minded billers. For many years, Red House Medical Billing and Credentialing, have utilized a team in Manila and Chennai. With this launch, they are offering expanding US-managed BPO services to the medical billing and broader healthcare industries.


What Sets Us Apart

Red House Services distinguishes itself as a team of US and Philippine-based managers trained to have a high cross-cultural competency. It is apparent that a BPO model is only successfully integrated into a billing department when there is a high-level global mindset. Not only do Red House teams have decades of billing experience, they train their clients about the cultural norms, business etiquette, and communication strategies of their new offshore teams. This allow them to be more competitive players in their space.


The Offering

Red House Services offers a spectrum of service levels from a hands-off Employer of Record to a full-service outsource model. Employer of Record partnerships create a team interviewed and hired by you. These people become your dedicated staff. Red House manages the complexities of payroll, Philippine government and tax issues, and HR tasks. When you prefer to simply outsource the workflows, the Red House team works as both the team and management reporting back to an operations touch point in your organization. We currently employ over 60 people involved in full RCM cycle work under our management. They work alongside the various Employer of Record teams. These models allow our clients flexibility to fit their company’s workflows. We assist our clients find their way to find a less expensive, better trained, experienced workforce.


RCM processes play the core role in our staff offering. These processes include data entry, eligibility verification, charge entry, AR, and payment posting. To augment our client’s success, we have a team of highly successful payor contract negotiators and credentialing staff. They may take on process work or clients may engage full time credentialers dedicated solely to their account. Finally, our services are able to Red House has staff ready to work for US, Australian, and Saudi billing clients.

Please, reach out to Jeff Hillam at if you’d like to discuss how a BPO partnership can augment your business trajectory.


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Expert Advice for Growing a Billing Company in 2022

3 Keys to Grow Your Medical Billing Company

Red House CEO, Jeff Hillam, joined other experts, hosted by AdvancedMD and InboxHealth, to discuss how billing companies can compete in turbulence.

Inbox Health asked, “Is your medical billing company poised to grow?” They answered, “With the right strategy in place, you will be able to manage a higher volume of patient statements and insurance claims with the same number of resources.”

In this webinar you’ll learn about best technology practices, marketing, M&A, and patient relationship management.

  • How to market your medical billing company for growth
  • What to look for in acquisitions
  • Tools to save time and run your business efficiently
  • Expert insight from the nation’s top medical billing professionals
  • Action steps you can take today to better manage increased demand for medical billing services