What Is Provider Credentialing?

Credentialing is required of all health care providers.

When a health care provider is hired to work at a hospital, clinic or specialty practice, she must have all of her qualifications reviewed in order to be credentialed, which allows her to care for patients through their insurance plans. Basically, doctors who want to bill the insurance companies for services must become credentialed in order for insurance companies and their plans to accept them.

History

More than 2,000 years ago in Persia, the ancient cult of Zoraster had specific procedures and guidelines for credentialing to be licensed as a physician. One of the first credentialing tests for these Persian health care providers was to treat three patients. If all three lived, a doctor could practice medicine for the rest of his life, but if all three patients died then that physician was no longer allowed to practice medicine. During the Middle Ages, credentialing became more strict in Europe where specific training was required to become a doctor. During the Renaissance, the credentialing process became more thorough, requiring not only a specific education, but every doctor also had to pass an oral examination by a committee of experienced physicians. Today, the process is more lengthy and complicated, but all health care providers must still become credentialed in much the same way as doctors of the past in order to practice medicine legally.

Significance

Modern day credentialing is significant because of its direct link to managed care systems. Credentialing is not as centered around licensing as it is around qualifying a provider for a health maintenance organization (HMO) or preferred provider organization (PPO) within an insurance company. This has health care providers jumping through insurance industry hoops instead of just dealing with the usual obstacles to state licensing.

Types

The credentialing process is unique to each hospital, clinic or practice based on the insurance companies involved. Different credentialing processes can review qualifications as general as education, board certification, references, hospital privileges and state licensing. Credentialing can also look into more specific information about a doctor such as previous work history, malpractice claims, criminal records and past sanctions against their license.

Time Frame

Credentialing has become a very involved and complex process that takes at least three months, but credentialing professionals are usually overloaded, which stretches out the process for up to six months. Even with personnel who work specifically on credentialing, there is so much back-and-forth between various certifying organizations and the insurance companies that everything moves at a monolithic pace.

Misconceptions

Many people assume that credentialing of providers simply involves the state licensing of doctors, but credentialing is specific to each hospital, clinic or practice. This means that a doctor must often be credentialed all over again if he wishes to move to another job, even if that job is in the same state. If a provider moves to another job that has the same managed care systems available and takes the same insurance as the previous job, then credentialing will be easier. Credentialing, however, is not simply the licensing of a health care provider within a state.

References

• ACP Hospitalists: A Brief History of Credentialing
• Med-Advantage: What Credentials are Available for Verification?
• Physician News Digest: Managed Care Credentialing of Physicians
• Softheon: Health Care Insurance Provider Credentialing
• Aetna: Description of Aetna Credentialing

Resources

• Provider Credentialing Resources: Credentialing, from start to finish
• Credentialing Resource Center: Welcome