Question

what is credentialing, discussthe types of credentialing process for physicians, hospitals and other healhcare facilities (snf, ambulatory seurgery center) and how credentialing affects payer provider contracts

Answer 1

#. Credentialing protects healthcare organizations and institutions from legal liability that could result from the actions of unqualified providers . It is used by hospitals and regulatory agencies to validate the educational and work backgrounds of providers. It occurs at the initial appointment and reappointment to a medical staff of a hospital or provider network. It is based on objective evaluation of a person's current licensure, training and/or experience, competence, and ability to perform the privileges requested.

#. Forms of credentialing :-

- licensure

- registration

- certification

- accreditation

- charter

- recognition

- approval

#. The Credentialing Process

1. Physician requests application must be

done at least 90 days prior to

expiration of current license

2. MSSP (Medical Staff Service

Professional) sends application and

other forms (this could be You!)

3. Preliminary Screening Done

a. verify;

1. education & training

2. Liability Insurance

3. Current Licensure (verify with the

state)

4. Clinically Competence

5. Description of health status

4. Query NPDB (required by law to obtain

report from NPDB on all physicians)

DEA check

5. Verified Information sent to department

Chairmen for review

6. Credentials Committee of medical Staff

Reviews

7. Sent to Medical Executive Committee

8. Sent to Governing Board who decides

and grants credentials.

#. Payer contracting, whether it is commercial payers or government payers, and the credentialing process is complicated, cumbersome, lengthy and time-consuming.

The sooner a practice can get a provider credentialed, the sooner it can bill and get paid. Reciprocal to this the longer it takes a payer to credential a provider, the more money they save since the practice may not bill for services delivered by un-credentialed providers.