The Difference between Privileging and Credentialing

The Difference between Privileging and Credentialing

You can often hear that hospitals use the term credentialing while making decisions regarding its practitioners and granting privileges. These two terms are related, but still quite different.

Basically, the term credentialing means the verification of physician's education, experience and training. Hospitals may also extent the term to include evaluation of collected data and making a decision about a physician. In this case, hospitals say that a physician has been credentialed as a staff member.

There are many types of credentials, but three main ones are used by all hospitals - licensure and re-licensure, college or university degrees, postgraduate work, certificates and awards. Some hospitals also require a proof that the physician has completed either a defined number of certain patient care treatments under supervision of a professional or an accredited training program for the activity he/she wants to perform. Hospitals perform a thorough check of all physician background information, and can search for signatures of supervising professional, documentation of special training and education, log book's recordings, etc. To give credentials, hospitals also check fellowship or residency training, board certification, and competency-based education.

Privileging is something different. The term means that a physician has been allowed to perform certain activities in a healthcare facility. It's important to understand the differences between privileges and membership. Membership means that a physician is a member of medical staff and can attend meetings, vote and receive benefits of the membership. There are also requirements that come with membership, such as attending patients in the department, paying dues, etc. Privileges are required in order to provide treatment to patients.

The processes of privileging and credentialing are defined at hospital's bylaws and in policies and procedures. Getting credentials and privileges is a necessary part of providing services to patients. Most of the time, the first step in the privileging process is to get an application for privileges. It's quite common for hospitals to create application packets that include the list of data required to get privileges. The physician submits a list of the requested privileges and proves that his/her credentials are real. The main task of credentialing is to verify the physician's qualification. Sometimes hospitals can grant temporary approval of privileges, while the credentials are being verified.

Credentialing process is usually held by a credentialing committee, which can also grant privileges. The credentialing committee consists of representatives of physicians who have privileges in that healthcare facility, and they make recommendations about the applicant to the governing body (for example, the medical staff executive committee). Different hospitals may have different committees. They can be composed of medical staff with administrative representation, or be more of an inter-professional group.

In some hospitals, staff is required to take care of the administrative process of credentialing and privileging processes, and then they should send information to the administrative body for a final decision. Besides, demand for credentialing has created many private credentialing services. These services usually help process application packages, verify credentials and send information to the organization.

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

How To Effectively Manage Credentialing Process

How To Effectively Manage Credentialing Process

Ensuring that your providers are credentialed is the crucial part of saving the practice. From education background to clinical research to board certifications, a lot of data must be collected and verified for each physician to confirm that they meet necessary qualifications of a healthcare specialist.

Have a look at the new recruit's data

When you're recruiting, try to align the credentialing process and the recruitment. Most employment contracts are built on the fact that the employer should get credentialed, thus if the physician doesn't get credentialed, that's a disaster for all parties. The leader of the hospital is 6 months behind in hiring a new physician and reputation is ruined for bringing a provider who can't meet the standards. The new physician may have relocated the job and waiting for a paycheck that will never come. Besides, he can even sue the group for failing to provide the promised job. And when providers don't get credentials, private insurance companies, Medicaid or Medicare can refuse to pay for certain procedures, reducing your incomes. Therefore, its leader's responsibility to check all physician's references, background information and demand explanation for any questionable data before offering the job.

By reviewing all gaps in employment, malpractice issues and references you can make sure the physician won't have problems with the credentialing process. Sometimes, credentialing committees ask for additional information and explanations. It can be asking simple questions about any given reference, or reviewing malpractice suits. The committee can also send documents to a third party for an independent check.

Keep all information in one place

Get credentialing software to keep all information secured inone place and allow staff to view the credentialing process and tasks that need to be completed. With provider's data and supporting forms connected in a single accessible record, your staff can rapidly provide and update their information. Besides, many different credentialing programs notify you about licenses that are near expiration, so you can proactively manage re-credentialing process as well.

Hospital credentialing is not the easiest process to complete, but at least it is more serious and organized now than it was before. However, new physicians still have to provide all applications and forms during the process. And hospitals must protect their patients. It's their responsibility (even though they have to rely on physician references), and hospitals can get sued over poor credentialing or end up in a court when a physician has its privileges removed.

What are the chairman's responsibilities during credentialing process?

It's chairman responsibility to investigate all the skeletons. If you're recruiting a physician who has some questions on the records, devote some time and get all the details explained, so that you won't have to fight problems during the credentialing process. If there is something that looks like regret, now it's time to search for another recruit. But if you still believe that the physician provides quality care, spend some time discussing all the problems with the credential committee to see what they need in order to finish the credentialing process.

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

How To Find A New Provider?

How To Find A New Provider?

If you want to change a doctor, you should go through a seemingly simple process - leave one doctor, find and see another one. When you think you have enough reasons for changing providers, you'll want to be sure you get the perfect one. If you don't do everything the right way, you may have a lot of headaches when it comes to finding a person who can meet your needs.

Things to do before you leave your current provider

If finding a new doctor is not mandatory and just your choice, perform a little search to be sure there are candidates that suit your needs. Some doctors don't take Medicaid patients, others don't treat new patients. Skillful specialists are booked months in advance, and you need to spend some time finding a new doctor before leaving another behind. Don't forget to schedule a visit with your current doctor. Take notes and ask a report on recurring and current conditions. If possible, take a new provider with you. You can also explain reasons for leaving - even in big cities the community of specialists is small and you don't want any rumors about your hospital.

Your leaving doctor should give you all copies of medical records that relate to chronic or current problems of the patients, which can be useful for a new doctor. Besides, it's required by HIPAA government policies that you can access this information. However, there are different laws in each state about health records, and how they should be carried out. Besides, if your doctor prefers EMR (electronic record keeping), then you can ask your new doctor to use the same system and alter the process. Once you've had a conversation with a leaving doctor and collected all copies, you can start to get a new one.

Visiting the new provider

Assuming that you have a replacement for the leaving doctor, there are necessary steps to develop the right relationships with the provider. Make an appointment with the new doctor and talk generally - it's better than talk while having sick patients or discussing problems at work.
You already have all the copies, but it's a good practice to have a second set of the records so that you have one set and your new doctor has the second set. If possible, send the copies as soon as possible and don't give them during your first meeting - it's better to have more time to talk rather than to read documents.

Think about the questions you want to ask your new doctor and write them down. It's up to you if you want to tell the new provider why you left the other one behind. If you decide to share this information, remember that it's a foundation for the new relationships. Discuss everything politely and respectively. You need a professional relationship, and that's going to be the start.
Once you work with your new doctor, remember that you need to invest a lot in the relationships. Your new provider will help your patients, so it's your responsibility to provide them with quality health care.

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

Main Aspects of the Affordable Care Act

Main Aspects of the Affordable Care Act

The Affordable Care Act, or ObamaCare, is the reform law that improves and significantly expands access to curbs and care spending through taxes and regulations. The main focus of the Affordable Act is to improve the quality of health insurance and health care, provide more Americans with access to affordable insurance, regulate the whole industry, and reduce health care spending in the country. There are hundreds of different provisions in the law that addresses multiple aspects of the healthcare crisis. It's understandable that you may not want to read the entire law, so below you can find the most important facts you need to know about ObamaCare to ensure you don't pay additional fees and get affordable coverage.

According to the Act, Americans who make less than 400% of the FPL (federal poverty level) will qualify assistance subsidies. There are three forms in which the assistance comes: cost sharing for reduced out-of-pockets costs, premium tax credits for reduced premium costs, and both CHIP and Medicaid. All in all, the Act contains more than thousand pages about new reforms for health care and insurance industries in order to reduce health care costs and provide affordable insurance for Americans. However, even though the law is long and complex, first 200 pages contain the most interesting information.

Before the Affordable Care Act, anybody who had been sick in the past (a pre-existing condition) could be simply denied treatment or coverage, or be charged much more because of the gender, or be dropped somewhere in the middle of the treatment because of a small mistake in the application. Moreover, you had literally no way to appeal insurance company rules. Now, Americans have a larger number of benefits, protections, and rights concerning their insurances.

In 2013, almost 45 million Americans didn't have a health insurance, which is 16% of the population. Those were working families who just couldn't allow the insurance. ObamaCare's main aim is to help those individuals to get insurances by offering cost assistance and expanding Medicaid eligibility. As a result, at the end of 2014 only 13% of Americans couldn't obtain the insurance. By 2015, the rate was below 10%.

The Act dramatically reforms Medicare. For instance, one of the changes is offering Medicare recipients the same rights, protections, and benefits as others, and reforming its system such as cut off redundant aspects. Remember that Medicare is not the part of the marketplace, and if you have Part A or C you're covered.

The Affordable Care Act requires large employers to provide their full-time workers with health coverage. Non-exempt Americans have to keep essential coverage the whole year or pay fees every month they go uninsured. The minimal coverage you need to have to avoid fees is the minimum essential coverage that can be obtained during the enrollment period.

Simply put, now everybody can get insurance regardless of previous health conditions. However, there is one exception: individuals with those health plans that were purchased before March 23, 2010, and have a pre-existing health condition don't have to cover costs related to their illness.

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

How To Choose The Best Physician Credentialing Software

How To Choose The Best Physician Credentialing Software

The current shift from fee for service to fee for quality has attracted bigger audience to health management. Those healthcare organizations who want to ensure efficient clinical delivery base should have started consolidating clinical providers at higher rates. Hence, new credentialing software is needed to handle all the complexities of multi-provider, disturbed, quality driven reimbursement model. The proper credentialing software has to offer are venue-centric solution and help healthcare organizations meet their financial and operational needs that healthcare management requires.

24/7 accessibility

Before buying credentialing software, go through all its features and evaluate if it can perform everything you need. At the very least, it should have 24/7 accessibility, so you can get your credentialing data at any time. All information should be stored in the cloud where healthcare managers can identify where they are in the credentialing process and ensure you aren't losing revenue on delayed applications. Moreover, being in a cloud means a reduction in capital expenditures since there is no need for another software, servers and hardware to subsidize the credentialing system.

Financial performance and payer operational metrics

Another important feature is institutional, financial performance and payer operational metrics. It means that leaders and managers of a healthcare institution can identify how the facility is performing from the financial and operational perspective. It also allows evaluating provider's individual performance. As any leader knows, understanding performance of providers is the first step of improving financial performance.

Generated work list capabilities

As a leader of a healthcare facility, you should require system generated, flexible work lists that your staff can use to meet their credentialing demands. No more calendars and post-in notes that remind you about stages of the credentialing process. The efficient credentialing software will help you go through each step quickly and without mistakes. Besides, healthcare leaders can easily evaluate the work of their providers and establish different metrics.

Assurance tools and mechanisms

The ability to track and monitor credentialing processes of the providers is a necessary feature of credentialing software. Quality monitoring and staff training should be ongoing, don't just leave it be.

Productivity tracking tools

Credentialing software should be able to track statistics and productivity metrics. What is your staff doing on a weekly, daily, or hourly basis? Are these just miss-guided, pointless efforts? The ability to track productivity metrics makes providers more efficient and ensures you're not losing revenue.

Combined credentialing concepts and revenue cycle

Understanding financial impact of the credentialing process helps meet the demands of health management initiatives. And when you know the impact, you'll see if you're losing revenue because providers aren't credentialed properly.

Revenue management

Credentialing software should give you suggestions that help ensure profits and sustainable growth of the facility. Keep all the processes streamlined and build a close network to keep your facility going.
Investing time and money in advanced credentialing software is always a good idea. Otherwise, you risk facing credentialing denials and lost revenue.

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

Free E-book

Now Submit Your Email and You Can Download 

This Free Informative E-book.

The Complete Guide to Physician Credentialing

The Need-to-Knows about Credentialing...

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

Physician Criteria For Privileging

For many years, hospitals throughout the country have granted privileges using so-called laundry lists. Laundry list or privilege list is a detailed checklist that shows procedures and treatments that physicians can request to treat patients or perform these procedures. The American College of Surgeons was the first who recommended laundry lists because many physicians had not finished an approved residency programs in a certain specialty area. The laundry list has gone through modifications but remains in use to the present time.

Nowadays, almost all physicians who apply for privileges have completed a training program and the original use of laundry lists is no longer relevant. However, even though the privileging process is easier now than before, laundry lists are a common approach to the delineation of clinic privileges in many hospitals.

Laundry lists include not only procedures and treatments available at the hospitals, but also criteria that must be met. Thus, physicians check off procedures they would like to be allowed to perform and go through criteria for each procedure. When using the list, physicians don't have to provide documentation of experience and training to show that they are qualified for all privileges. Physicians are allowed to choose which criteria they can meet before applying for privileges.

Those hospitals that don't have laundry lists use criteria-based privileging. It combines predefined criteria with well-defined, realistic privileges. The term core privileges mean clinical activities within a certain specialty that any actively practicing, properly trained physician with good peer recommendations would be able to perform.

At hospitals who use the criteria-based privileging system, those physicians who meet predefines criteria can apply for privileges, and those who proved additional training and experience can apply for noncore privileges. Special privileges almost always correspond to one of the following:
•    volume-sensitive diagnoses
•    new advances in technology
•    high-risk treatments

If a physician meets required criteria to request privileges are supported by references attesting physician's competence, privileges can granted.  If a physician requires additional privileges, a separate verification procedure is required. The same is true for performing unusual treatments and procedures - for example, what would otherwise be a basic procedure, like a surgery, with a robot instead of a doctor require the separate privileging procedure.

Physicians who can't meet predefined criteria in a particular specialty may still be qualified for limited privileges by providing honest evidence that they possess proper training and experience to perform the requested procedures or treatments.  For example, a family physician can apply for a specific set of privileges on the obstetric list, for example, to perform the cesarean section. But to get the privileges, that physician would have to show to the hospital credentialing committee that he/she has required training and experience that is necessary to get privileges and perform cesarean sections.

One of the main advantages to the criteria-based privileging approach is consistency. All physicians are asked to meet the same standards and prove that their education, experience, training, etc., are suitable for the privileges they'd like to get.

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

What's The Difference Between Credentialing And Contracting?

If you're a health department that wants to start a billing program or is going to expand, you have probably heard the terms Contracting and Credentialing before. These are very important steps that you have to complete, or you can't bill private insurance companies for services your hospital provides, losing a huge part of revenue. But what these two terms mean and where should you start?

The main points of credentialing

Local health facilities can start billing insurance companies only after they've got credentials. Credentialing is a process that private insurance companies use to verify, obtain, access, and validate a healthcare facility in order to ensure it's a reliable place and for liability purposes.

The start of the credentialing process, create a file folder for an insurance company. Different companies require different documents and forms, and folders will save your time and help you to simplify and organize the process for every payer. To choose the best insurance companies among many others, try to create a survey and ask your clients about their companies to see which are used the most. The most common ones should be among the first ones.

After you have created the list of companies to get credentials from, you'll need to get acquainted with the requirements for every company. Each insurance company has a web page where they state all necessary forms and requirements. From there you'll get all relevant information, provide all documents and fill out all forms. Submit everything you get, and you should get credentials within 180 days. And when you're credentialing, it's time to think about contracting with companies.

The main points of contracting

Contracting refers to the process of creating agreements with private insurance companies to become one network with them. It includes establishing services covered, rates, payments, and other information with each company. Every company requires a separate contract.

If you find credentialing process hard, then you should know that contracting is much harder. You will have to negotiate a lot of things with all insurance companies and your success depends on talking to the right person within each organization. You can try to speak to directors and administrators who have some useful contacts to make the process easier.

In today's world of revenue cycles and health insurance, it's important to remember that improper credentialing may lead to serious consequences, such as denied or delayed reimbursement for services provided. Even worse, it may lead to consequences in terms of compliance violations, which means criminal charges and monetary damages.

Some payers take a long time to get to your case and you may face multiple delays. They arise from the non-standard language some organizations use. Sometimes you will have to work with payers to revise the language. It will require even more time.

Healthcare payers often don't know much when it comes to understanding what billing services what local organizations provide. So, it's always a good idea to be persistent and remind them from time to time that it's very beneficial to contract with your facility.

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

How to Avoid the Most Common Credentialing Mistakes?

Credentialing process is a necessary part of a successful physician practice with steady cash flow and patient referrals. Avoiding these common credentialing mistakes will make the process move more quickly and efficiently.
Providing incomplete information
The most common mistake many physicians make is a lack of attention to small details. Errors and mistakes in application lead to delays and even denials. Different healthcare facilities may have different application forms, but typically you need to submit your phone, tax, address, services provided, contact information, employment history, copies of licensure, patient profile and legal troubles regarding your practice if you have any.
What can you do? Thoroughly check your application a couple of times to certify its accuracy before sending it to the credential committee. Getting everything right the first time means you get credentialed much faster.
Not following up
Be prepared that your plans can be backlogged with the credentialing process. Do everything you can to confirm that your application was successfully received and know where it is. If something sounds like complete nonsense to you, ask questions and wait for the response. Many physicians have no idea of where in the process their application is and what each stage means. Make sure you have no more questions before accepting the answer.
Follow up from time to time and don't forget to make notes. E-mail your contacts, phone if you need to and check all web directories. Never call to explain delays or notify about updates. The only way for you to find out something about the application is to follow it up regularly. Make it a routine and keep up until your application is approved. Remember that you're the one who is concerned about the process.
Don't allow CAQH lapse
If you already have a CAQH profile, you know that it should be updated regularly. Always keep up-to-date all contact information and re-attest your data. You should act proactively when you receive an updated insurance, license, DEA or any other document and get everything loaded to your profile with new expiration dates. It will help avoid delays in the process of re-credentialing.
Not knowing the standards and guidelines
Application forms in Medicaid, Medicare and other government health programs are completely different. They all have standard forms that must be appropriately filled out and sent to the intermediary. These applications, then reviewed against very strict standards. Many physicians make the same mistakes in the following:
• Using outdated/irrelevant applications
• Using incorrect forms
• Submitting incomplete applications
• Submitting to the wrong intermediary
• Not submitting required forms
• Not using verifiable practice location as a practice address
• Not signing the application in all fields
Not giving enough time
Many physicians start too late and this is a reason for their failure. You really need to give yourself at least 3 months. The responsiveness of your application will be determined by the motivation to add a new doctor to a team and the workload.
Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

What's Important To Know About The Credentialing Process?

Physician's credentials - certificates, diplomas and licenses on the wall - tell patients about their professional skills and qualification to treat them. In the US, professional organizations, state and local governments establish the credentials that physicians need to provide their services.


Practitioners are credentialed and then privileged - healthcare facilities verify education, license, and qualification - upon hire and then every two years. Physicians can get privileges after thorough evaluation and verifications of the training and education they have presented. Privileges allow physicians to give the care treatment and services by the facility to the patients.


The most important thing to know about the credentialing process is that there is no national, standardized system for credentialing physicians. Each state and local government is responsible for deciding what physicians have to provide to get credentialed. Those credentials may vary quite a lot from state to state and among different disciplines.


Patients should note that certificates, licenses, and regulations can't guarantee effective, safe treatment from any physician - complementary or conventional. Tell your physician the complementary health approaches you prefer. Tell them everything you do to take care of yourself. This will ensure safe and coordinated care.


Apart from credentialing, you could also hear about certifying and licensing. Credentialing is the broader term that refers to doctor's license, certification, or education. Professional organizations give certifications, government agencies grant licenses. Note that being certified or licensed doesn't mean being qualified.


The vast majority of states use the approaches below to credential doctors:
•    Title licensure: requires doctors to obtain credentials prior to using a title
•    Mandatory licensure: requires doctors to have licenses to treat patients
•    Registration: requires doctors to provide information about professional education, experience, and training


To get a license, you should carefully read requirements of each state. Among everything else, they may ask you to:
•    meet certification requirements
•    graduate from a certain program
•    pass exams
•    Complete a training program


The services you're allowed to provide also vary from state to state. For example, some states don't allow acupuncturists to recommend diets to patients, while others recommend doing it.


Some professional organizations offer additional certification examinations. Certifications qualify doctors for local or state licensure. For instance, in some states, doctors who don't have an M.D., have to be certified by the National Certification Commission if they want to be licensed.


Educational programs in the US train physicians and prepare them for future certification. The Department of Education authorizes specific organizations to accredit training programs for doctors.


The credentialing processing time varies from one organization to another. Sometimes plans take 6 months to complete the process and then 50 days for contracting, while others need 3 months to finish everything. When you submit documents for contracts, enrollment or follow-up on your application, it's important to keep track of the process by utilizing fax logs, certified mail, and documenting all conversations. Once the credentialing process is complete, you will be offered a contract and will be able to treat patients in the facility.


Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

How Long Does It Take To Complete Physician Credentialing?

It's quite common that a new physician joins your healthcare facility either from another practice or out of residency. It's the time when you have to deal with many managed-care organizations or MCOs, so your new physician needs to be credentialed.

This process requires a lot of time and effort. First, you have to collect all documents from the provider - from valid state license to hospital privileges to confirmation of malpractice insurance. Then you have to wait at least 30 days (but it usually takes longer) for the MCOs to check and verify documentation before the new physician can be added to the panels. During this time, the physician is not allowed to treat your care patients. At least, the physician will not be reimbursed for treating, which dramatically limits the ability of the physician to create revenue for your facility. At this point, many start asking why this process takes so long. Is there any way to reduce delays? Below you can find some tips to help you and your facility.


Why is this process so long?
There are many reasons for delays, but the main ones are MCO's desire to match the NCQA (National Committee for Quality Assurance) standards and inefficient planning on the part of practices and physicians.
One of the NCQA standards that are called the Initial Primary Source Verification stipulates that the MCO should verify several documents, like records of professional liability settlements, prior to assigning credentials. When the MCO really wants to meet this standard, they make withhold credentials from a new physician until the very last detail is verified.

Poor planning is also a popular reason for delays. Quite often, new physicians don't start credentialing process until they arrive at practice, even though they've started filling the applications months earlier. And there can be a huge delay since collecting references can take months and then weeks until they arrive. Until all information arrives at the MCO, an application cannot be considered complete - and while it's not complete, the credentialing process is stalled.

For that reason, many healthcare facilities require submitting application at least 90 days before the physician's start date. The processing time can take less than 90 days, but it's a benchmark since it allows extra time when some documents can't be verified in timely manner or discrepancies is required.

You should just keep in mind that credentialing process will take as long as needed to collect all information, receive board recommendation and verify all sources. It's hard to estimate the minimum or maximum frame for the credentialing or privileging process, which both may take longer than three months. Medical staff bylaws, which define privileging and credentialing processes, specify that applications must be acted upon a certain period of time. Some credentialing applications may be finished faster than others, and it always takes longer if the primary source can't be verified, if a physician omitted information or made mistakes on the application, or if there are red flags that require careful investigation.

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

Why Is Privileging Important?

 

While we all hope that our doctors have the highest qualifications, there are cases when patients suffer inappropriate care. At many hospitals across the country, where quality care is their biggest concern, medical staff always struggle with the task of properly privileging their physicians.


There are at least two reasons for this. The first one is medical board requirements and rules that vary in each state, making it quite difficult to hire physicians from different states and develop credentialing standards. The second one is that appropriate privileging training has sometimes been inefficient, mainly due to the lack of appropriate healthcare facility's resources and personnel.
However, hospitals still stick to the privileging process and try to make it as easy and quick as possible. Below there are the main reasons for granting privileges, and how to make this process more pleasant.
Understand the importance of the process
Every healthcare facility should understand that no provider can be allowed to provide services until he/she has successfully met the requirements of a privileging process and proved the competence and experience. Hospitals should begin by collecting applications that have all necessary information (for example, certification and training). Then this information should be verified through reliable sources to ensure that this physician data is valid.
Complacency cannot lead the privileging process
The very first goal of any reliable healthcare provider is to deliver the highest quality patient care, thus hospitals have to go through all necessary steps to develop a perfect and clear privileging process and reevaluate and update the process to ensure the best results. Evaluating new physicians and assigning proper privileges can take a lot of time even under the best circumstances. The better your process is, the sooner you'll grant privileges to a physician, thus the sooner he/she will start treating patients and brings you more revenue.
Look outside the box
When you're evaluating credentials applications and files, having everything done properly and get all the documents is quite important, but it is not a guarantee of success. Sometimes physicians don't include information that is as important as data that is included, and it can require a well-trained credentialing expert to get rid of useless information and find important nuances in physician's life and practice.
Appropriately trained credentialing specialist is recommended
Lack of privileging success is quite often due to incomplete, insufficient, or improper resources and personnel. Unfortunately, erroneous or incomplete decisions based on fake information (which results in granting privileges to an incompetent provider) can compromise the quality of patient care. It's really important that a hospital takes all appropriate steps and has the most highly trained staff.
Explain to your staff the importance of privileging process
It's vital that your committee members, physician leaders, board members and senior management understand the importance of privileging. Obtaining their support will kick off the whole process on the right foot and dramatically improve chances for success. For healthcare providers that provide honest information and meet the standards, the result of the process is predictable. And when you get a perfect physician, he/she assures the highest quality care possible.
Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

Why Should Hospitals Credential Their Providers?

Hospitals and other health care facilities are required to verify the qualification of those who provide services to their patients. In order to ensure patients receive safe and quality care, physicians have to undergo a process, which is called a credentialing. Credentialing process means a practice by which healthcare facilities verify skills and qualifications of their providers to ensure each patient that they possess necessary skills to provide services to patients. Once a physician is credentialed, hospitals have to further investigate practitioner's competence in a concrete area of care, through a process that's called privileging.


The main principle of the credentialing is the responsibility of hospitals for ensuring quality care for each patient. In multiple efforts to reach this aim, healthcare facilities take numerous steps to verify proficiency of their providers through the collection and evaluation of information relevant to the professional performance of the practitioner. These two processes happen after a physician has already met licensure requirements.
In the vast majority of hospitals and healthcare facilities, physician credentialing has two stages. During the first one the hospital checks that the physician has completed education and training, can practice in the state where health care is being administrated, and does not have violations and malpractice issues on record.


Applicant identification is one of the first things a physician has to go through. The application requires a copy of an ID with a photograph. It's also recommended to send a copy of the picture when a healthcare facility requires references from the applicant. This would prove that the applicant didn't use an ID and a photo of another provider. Moreover, in many states it's mandatory to perform a thorough background check on all physicians. This background check differs from verification of provider's data. Many healthcare organizations even hire a third party to provide a comprehensive investigation of court records - both civil and criminal - at the state and federal level.


Hospitals have to collect a lot of information regarding each physician's licensure status, experience, training, ability to perform privileges and competency. Verifying that all providers meet the standards and that there are no questions about their behavior, credentials, references, education and training help filter out troublesome or incompetent candidates. The hospital's bylaws should develop a process for approval and review of all applications and reapplications. All credentialing, privileging and re-credentialing recommendations and decisions have to be documented and approved by the governing board.


Moreover, there are healthcare facilities that require their providers to undergo another credentialing process, which is known as periodic credentialing. This process allows hospitals to double-check the qualification of their physicians.  During this process, hospitals have another opportunity to verify one more time the competency of their providers.


After the credentialing process is done, the hospital gives the physician a permission to deliver services in the healthcare facility, be it cardiology, surgery or anything else. Once the hospital is sure that a physician's competence in his field of practice is real, the physician gets credentials and privileges.

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

How Can You Protect Your Hospital From Unprofessional Physicians?

It's a proven fact that in order to predict somebody's future behavior one should examine the past behavior of that person. Thus, the best way to hire the most professional physician is by examining his/her background and work history. Below you can find the key components of the successful credentialing process.

Ask about any malpractice issues

Every hospital can create its own application form, and yours should ask detailed information about formal warnings or reprimands, or if the applicant has ever been put on probation. You should clearly explain that omission of any important information in the application can be a reason for an immediate loss of credentials and privileges. You should require the National Practitioner data Bank and review the results searching for evidence of professional misconduct. New recruits should be asked about their professional knowledge and references. If the recruit has references stating anything but good professional behavior, he/she should get in contact with medical staff leader for an explanation. And also a little note about references: always ask new recruits for references that can shed light on the professional conduct of the new provider. If the credentials committee thinks there have been issues with unprofessional behavior, they will contact individuals who could have direct knowledge of the misconduct. It's the applicant responsibility to provide you with honest references and until they are returned, credentialing process is not complete. And if former medical staff representatives or hospital personnel are reluctant to speak about behavioral concerns regarding a physician applying for credentials, ask the physician to provide a specific release stating that he will not bring legal actions if those individuals are forthcoming with information.

Interview potential providers

Interviews are a great way to reveal some behavioral or personality problems. For example, you can ask a physician how he would respond if a nurse observes inappropriate physician conduct in the facility. If the applicant can't acknowledge inappropriate conduct of the physician or won't report it to the hospital leaders, consider it as a red flag. Moreover, those who show immaturity, defensiveness or self-centeredness are prone to unprofessional behavior more than others.

Credential committees can sometimes dismiss red flags on the ground that they're unsubstantiated because they simply can't find information about the applicant's past. As a result, you may end up hiring a problematic physician. However, good credential committees always ask applicants to provide additional references to help deal with concerns. For example, if there are rumors that the applicant has been disruptive elsewhere, the committee can require more letters of reference or interview the director of the previous hospital about the performance of the applicant. Credentials committees can also ask questions, like has this physician ever been disciplined for unprofessional conduct? Has he been the subject of an investigation? The credential committee should know applicant's past experience so they can ask complicated questions while processing the application. They can even ask the applicant to undergo a special evaluation. There are multiple organizations that analyze behavioral problems in applicants.

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

How Can You Apply For Changes To Privileges?

Getting hospital privileges is a complicated, time-consuming process. However, once a physician gets the privileges, he/she should renew them at least once in two years. In the past, it was done automatically, as long as a physician shows high performance and meets all standards. However, since 2008 hospitals are required to develop their own criteria to renew granted privileges based on different standards, such as patient satisfaction rate, mortality rate, complication rate, and even handwriting legibility. So, keeping privileges is quite a chore for physicians, and the only way to make it a bit easier is to get you acquainted with all steps.

Two parts of hospital privileges re-approval process
Re-application for privileges consists of two parts - re-credentialing process and new privileges determination. Re-credentialing process is held to check one more time if the physician still has skills and qualification to retain his/her privileges. The hospital staff performs another background check, evaluates the physician's performance throughout the year, and verifies training and education. Then you will be given your privileges again, which will allow you to do certain things in the hospital. Sometimes, a hospital allows you to retain all your privileges. However, they can also give your very limited privileges, restricting you to perform only one function or procedure. Or they can grant you with broader privileges, and you'll be able to do almost everything in your specialty, including consult, admitting patients, performing multiple procedures and so on. Moreover, more and more hospitals get associated with a particular practice. And if you don't belong to that practice, your privileges may be reduced or you'll get no privileges at all. That's the modern world of medical politics.

Basically, there are four steps you should go through:
•    Contact the office of your hospital and get their application form
•    Fill and submit everything properly and return it back
•    Follow up to make sure everything goes smoothly and medical staff has everything they need
•    Prior to the privileging meeting make sure you send all recommendations and letters of references

In some hospitals, there are also different types of privileges. Sometimes, you can even choose what is best suited for your practice. Courtesy privileges mean that a physician can admit only a number of patients. It's still enough for medical insurance companies to grant privileges to a physician. In this case, physicians usually don't attend medical staff meetings. These privileges can suit those physicians who don't expect to do procedures or admit patients at the hospital.

Full privileges mean that physicians can admit unlimited number of patients and should perform core procedures of the medical specialty. Physicians also have to attend medical staff meetings regularly.

The vast majority of medical insurance companies require physicians to hold privileges to be allowed to be part of any medical network. Obtaining the privileges isn't the easiest task, but it will prove you can provide quality health care. So, many hospitals help physicians to get their privileges.

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

How Can You Apply For Changes To Privileges?

Getting hospital privileges is a complicated, time-consuming process. However, once a physician gets the privileges, he/she should renew them at least once in two years. In the past, it was done automatically, as long as a physician shows high performance and meets all standards. However, since 2008 hospitals are required to develop their own criteria to renew granted privileges based on different standards, such as patient satisfaction rate, mortality rate, complication rate, and even handwriting legibility. So, keeping privileges is quite a chore for physicians, and the only way to make it a bit easier is to get you acquainted with all steps.

Two parts of hospital privileges re-approval process
Re-application for privileges consists of two parts - re-credentialing process and new privileges determination. Re-credentialing process is held to check one more time if the physician still has skills and qualification to retain his/her privileges. The hospital staff performs another background check, evaluates the physician's performance throughout the year, and verifies training and education. Then you will be given your privileges again, which will allow you to do certain things in the hospital. Sometimes, a hospital allows you to retain all your privileges. However, they can also give your very limited privileges, restricting you to perform only one function or procedure. Or they can grant you with broader privileges, and you'll be able to do almost everything in your specialty, including consult, admitting patients, performing multiple procedures and so on. Moreover, more and more hospitals get associated with a particular practice. And if you don't belong to that practice, your privileges may be reduced or you'll get no privileges at all. That's the modern world of medical politics.

Basically, there are four steps you should go through:
•    Contact the office of your hospital and get their application form
•    Fill and submit everything properly and return it back
•    Follow up to make sure everything goes smoothly and medical staff has everything they need
•    Prior to the privileging meeting make sure you send all recommendations and letters of references

In some hospitals, there are also different types of privileges. Sometimes, you can even choose what is best suited for your practice. Courtesy privileges mean that a physician can admit only a number of patients. It's still enough for medical insurance companies to grant privileges to a physician. In this case, physicians usually don't attend medical staff meetings. These privileges can suit those physicians who don't expect to do procedures or admit patients at the hospital.

Full privileges mean that physicians can admit unlimited number of patients and should perform core procedures of the medical specialty. Physicians also have to attend medical staff meetings regularly.

The vast majority of medical insurance companies require physicians to hold privileges to be allowed to be part of any medical network. Obtaining the privileges isn't the easiest task, but it will prove you can provide quality health care. So, many hospitals help physicians to get their privileges.

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

How Can You Apply For Changes To Privileges?

Getting hospital privileges is a complicated, time-consuming process. However, once a physician gets the privileges, he/she should renew them at least once in two years. In the past, it was done automatically, as long as a physician shows high performance and meets all standards. However, since 2008 hospitals are required to develop their own criteria to renew granted privileges based on different standards, such as patient satisfaction rate, mortality rate, complication rate, and even handwriting legibility. So, keeping privileges is quite a chore for physicians, and the only way to make it a bit easier is to get you acquainted with all steps.

Two parts of hospital privileges re-approval process
Re-application for privileges consists of two parts - re-credentialing process and new privileges determination. Re-credentialing process is held to check one more time if the physician still has skills and qualification to retain his/her privileges. The hospital staff performs another background check, evaluates the physician's performance throughout the year, and verifies training and education. Then you will be given your privileges again, which will allow you to do certain things in the hospital. Sometimes, a hospital allows you to retain all your privileges. However, they can also give your very limited privileges, restricting you to perform only one function or procedure. Or they can grant you with broader privileges, and you'll be able to do almost everything in your specialty, including consult, admitting patients, performing multiple procedures and so on. Moreover, more and more hospitals get associated with a particular practice. And if you don't belong to that practice, your privileges may be reduced or you'll get no privileges at all. That's the modern world of medical politics.

Basically, there are four steps you should go through:
•    Contact the office of your hospital and get their application form
•    Fill and submit everything properly and return it back
•    Follow up to make sure everything goes smoothly and medical staff has everything they need
•    Prior to the privileging meeting make sure you send all recommendations and letters of references

In some hospitals, there are also different types of privileges. Sometimes, you can even choose what is best suited for your practice. Courtesy privileges mean that a physician can admit only a number of patients. It's still enough for medical insurance companies to grant privileges to a physician. In this case, physicians usually don't attend medical staff meetings. These privileges can suit those physicians who don't expect to do procedures or admit patients at the hospital.

Full privileges mean that physicians can admit unlimited number of patients and should perform core procedures of the medical specialty. Physicians also have to attend medical staff meetings regularly.

The vast majority of medical insurance companies require physicians to hold privileges to be allowed to be part of any medical network. Obtaining the privileges isn't the easiest task, but it will prove you can provide quality health care. So, many hospitals help physicians to get their privileges.

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

How Are The Physician Privileges Determined?

All patients want good, skillful, qualified doctors. Naturally, hospitals want the same. That means that being a licensed physician is not enough to get hospital privileges. Hospital privileges can be called prescriptions that allow physicians to perform a certain set of operations and procedures, or even admit patients. As hospital executives say, without privileges, a physician can't be considered qualified.


There are several regulatory bodies - including Medicare, Department of Health and Senior Services, and Joint Commission on Accreditation of Healthcare Organizations- that hold healthcare facilities responsible for appropriately granting privileges to every physician before he can start practicing in the facility.


Getting hospital privileges is a complicated, tedious, and detailed process. But hospitals have to ensure patients get the best care. Physicians go through the similar process at all hospitals across the country, and each hospital is required to make an independent decision about the individual physician.


Before a physician, or any doctor, can treat patients in the facility, they have to fill out and submit the application asking for permission to practice at the hospital. They also have to obtain a permission to carry out certain procedures and treat patients at the hospital.


All of the physician's credentials - residences, education, training, experience, and fellowships - are carefully reviewed for appropriateness of competency and training. Most of the time, applications are verified by medical staff services and also reviewed by the leading physicians of the hospital.


Medical department's chairman and Credentials Committee set recommendations about special privileges and appointment to the staff. Then, their recommendations are reviewed by the Medical Executive Committee, and their results are sent to the Board of Trustees, which decide whether they approve the application or not.


If a physician meets all the guidelines and requirements, then he's granted privileges that he appear to be properly trained to carry out. Physicians can even obtain privileges to work in several hospitals, but the majority chooses to stay in one facility. However, privileges can be denied if the hospital decides a physician doesn't have a proper training or doesn't demonstrate competency. Besides, exclusion from Medicaid or Medicare, loss of medical license, or having found of abuse or frauds are reasons for withdrawal of hospital privileges. Privileges can also be suspended when a physician doesn't treat enough of patients to stay proficient or doesn't perform enough of procedures.


Physicians should state which specialty they want to practice, and all materials are sent to the chosen specialty. Then physician committee evaluates the application and makes the suggestion. However, the board decides whether or not grant privileges to the physician. If an employment contract allows, a physician can join more than one medical staff. Most often, a physician is needed at many hospitals when the specialty is narrow. It also helps to build the patient base and maintain professional skills.


Hospitals privileges are also required by many insurance companies that won't allow participating as a provider in the provider panels otherwise. For hospitals, it's also beneficial to grant privileges. It allows them to treat certain patients, improve medical equipment and generate revenue.


Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

Everything You Should Know About Privileging

Credentialing process means deciding whether a physician is skillful enough to perform services he wants to perform. This requires a lot of paperwork and can be done differently by different healthcare facilities. Once a physician gets credentials, he can apply for privileges, or the ability to perform specific procedures and treat specific conditions. This is done at each hospital and requires close examination of physician's application.

There are different ways to do the privileging process. The most traditional one is to create a list of all treatments and procedures. Applicants check if the hospital has procedures they wish to do. Then applicants have to prove that they have knowledge and qualifications to perform the desired procedures. Once applicants show that they can perform the procedures, medical staff searches for any subjects to supervision and decides whether to reject the privileges or not. This way of granting privileges allows medical staff to provide recommendations to the board about the applicant. Applicants can request only those privileges they really need and provide documents only for the data that look suspicious to the medical staff.

However, there is one potential problem - sometimes applicants simply forget to mark the procedure. As a result, they're not allowed to perform it. Besides, medical staff is required to check the competency of the physician to perform requested treatments and procedures. And, for example, if the surgeon wants to perform a procedure, he/she will have to check not only surgeon boxes, but OB/GYN and pediatric boxes as well.

Another way is core privileging. In this case, applicants pick one of the predetermined groups of treatments or procedures that are the most common to that specialty. However, medical staff has to include or exclude all procedures in core privilege list.

Whether method you would like to use, applicants have to show their experience, training, education and competence for the privileges they want to get. You should develop a predetermined criteria or standards and then verify applicant's skills against the standards. These criteria should apply to only one procedure or specialty, and not to the whole department. Your standards should be fair, equal for everybody and related to quality health care.

In order to verify education and training you should look at the background of the new recruit. Board certification is also a good criteria, but it should not be the only one in granting privileges.

Current competence can be determined by examining letters of reference which usually include information on the recruit's performance and improvements. Competition may also include examining the number of procedures performed, or patients treated. However, many skills cross over between different procedures, so the number of them may not show real skills of an individual.

After developing new privileging standards, a hospital should send them to a medical executive committee for the approval. The committee will review the standards and make sure they are fair. Then, the final draft is sent to the board. Once they are approved, medical staff has to follow them.

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

Credential Process Made Easy

Credential process has always been an integral part of the process of practicing medicine. For anyone who wants to treat patients, it's essential to have a document that proves they are allowed to do so. Yes, it is as simple as that. Credentialing is something that has been going hand in hand with medicine for many years.

There were times when doctors could simply treat first three patients, get a proper certificate and start practicing. Today, credential process is long and time-consuming and can cause headaches if not managed properly. Whether you're a physician opening a practice or just adding a new doctor to a team, you should start the credential process in advance - sometimes even nine months before you're going to see your first patients. If you're not in the plan, you can't work with patients. If you want to earn money, you have to be credentialed. And to get credentialed without problems, you should continue reading the article.

Get All The Papers Together In Advance
Start organizing everything far in advance. Mobilize your staff as soon as you find out the new physician is coming - or, if you're a solo physician, as soon as you decide where you're going to set up practice. Most of the time, you will need a proof of malpractice insurance and a license before you get all hospital privileges. And you need hospital privileges before you get credentialed by the plans. Note that many hospital committees meet quarterly, so you have to complete all paperwork well ahead of time.

As MD of Bakersfield Orthopedic Medical Group Alfred Coppola states, their manager started managed-care and hospital plans credential process well in advance, so that their new spine surgeon had a full appointment schedule on the same day he started seeing his patients.

Keep Track Of Your Documents
Managed-care plans are well-known for accidentally losing physician documents, applications and other stuff. It is strongly suggested to mail your documents as "return receipt requested". This way, you can at least prove that your application was received. Besides, somebody will have to review your application before sending it. Note that if you leave something blank, you paper can be put to the bottom of the big pile.

If you have some problems, speaking to a manager would be better than speaking to a front-line employee. If you spend some time building relationships with an authority, chances your document will get lost are lessened. It always helps when managers can put your face with your name. If your documents get lost, don't panic - consistent follow-up will help you find them. Call them regularly and ask the same person all the time. They will remember your name and your problem.

Don't think there are unimportant details - submitting incomplete information or leaving blank fields will cause delays as payers don't work on any application until you provide them all information they ask for. Note that a common application misses information in four main areas: malpractice insurance, current work status and work history (don't forget the physician's start date), covering attestations and hospital privileges. Besides, payers always have a deeper look at those who have gaps in service that are longer than a month. Provide all possible explanations in your application, so that nobody will have a reason to require additional details.

Don't be shy and look out for peers. An important part of the credentialing process for any physician is to serve as references for colleagues. If somebody asks you, provide turnaround as quickly as possible to avoid delays. Look out for other physicians and help fellow workers to finish the process.
Check your application multiple times to see if you get all the information right. If you submit everything properly, you will get credentialed within 90 days. And if you make a mistake, you will not be able to work with patients.

Whatever you're going to do, never try to modify any documents - be it letters from committees, letters of reference or any other paper. It can be quite tempting, but don't go for it. Chances that you will be caught are extremely high.

Be aware that the physician credentialing process is always frustrating and lengthy. Keep that in mind and don't act impatient or defensive toward the staff you're going to meet. Wait times often can't be controlled by credentialing staff anyway.

Finally, be thorough with your papers. It requires a lot of time at the beginning, but it will save even more time later.

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

Changes In Physician Credentialing Process

Just recently there have been some interesting changes in legislation concerning health care. New regulations require behavioral health programs to upgrade the standards of credentialing and provide the credentialing process differently.

Before you start worrying how your team is going to handle even more credentialing work, let's have a look at these changes and consider it as an opportunity to improve your administrative process.

How does it change behavioral health programs?
Those health facilities that didn't have licenses must obtain different certificates. Therefore, the following programs now must credential their providers:
• Nonresidential programs, such as day treatment, intensive psychiatric rehabilitation treatment, partial hospitalization, and PROS(personalized recovery oriented services)
• CPEPs (Comprehensive psychiatric emergency programs)
• Hospitals for mentally ill persons
• ACT programs
• Psychiatric inpatient units
• Treatment facilities for youth
• Apartment program

There is also new Medicaid Carve-In that should improve health outcomes, quality of care, and reduce healthcare costs. Medicaid will implement managed-care model instead of fee-for-service model. Within this model, Medicaid will:
• Provide necessary recovery-oriented services
• Ensure individual-centered care management
• Make outcome-based payments
• Provide client choices
• Improve behavioral health services
• Track behavioral health spending

Now, there are Health and Recovery Plans available for people who need significant mental support. To be able to administrate HARPs, a hospital has to increase credentialing requirements and ensure the program has:
• Adequate network
• A process that can handle the new credentialing process
• Experienced staff
• A compliant credentialing process

There is going to be a data management platform that allows hospitals to manage and maintain information about the credentialing process. The main thing you should do to meet the requirements is to constantly update data on the platform. Specifically, answer the following questions to maintain adequacy requirements:
• Is the hospital accessible to the clients?
• Are your providers able to meet the needs of patients?
• Can your patients understand what your providers tell them?

There is a simple solution that helps hospitals meet new credentialing requirements: new software. There are software systems that help handle data collected during credentialing processes. Usually, one system is enough to manage all paperwork. Note that this software can cost quite a lot and may not have a user-friendly interface. However, nowadays almost every person is technologically savvy and can quickly get acquainted with new software. Moreover, modern software is easier to manage and has improved interface.

The credentialing process serves both patients and providers, and physicians have the right to expect recognition of their efforts, so they need to provide relevant information that reflects what they really do in practice. Lots of feedback has been provided concerning unnecessary difficulties during the process, so we can expect further changes that will make everything a lot easier. For now, there are still lots of costly applications and time-consuming processes that physicians have to go through every 2 years.

Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.

Blind Spots in Physician Credentialing

Every physician knows two questions patients ask - "Have you done this to somebody else?" and "How does the hospital let doctors practice in the facility?" These are understandable and straightforward questions. At the end, we constantly check our all service providers at sites like Angie's Kist or Better Business Bureau. And still, the medical profession and the way its self-policing is shrouded is still a mystery.


One of the main secrets almost all states' health law has is that there is a "corporate practice of medicine" doctrine. It says that hospitals can't employ doctors at all. Confused? It simply means that hospitals can't practice medicine, only doctors can. Never mind that many hospitals advertise they have the best and the most professional doctors in the field. Hospitals can employ administrators, technical personnel and nurses. Doctors, on the contrary, are independent contractors and not hospital employees. That's why when a patient is accidentally injured because of medical errors, the people in the hospital point their fingers at doctors and remind that doctors don't work in hospitals.


But these independent contractor doctors can somehow come to work in hospitals. How? That's the second important secret of the health law - physician credentialing. Credentialing refers to a process that hospitals use to decide whether or not they should let a doctor practice medicine at their facility, including the list of activities that the doctor can perform there. As a simple example, a neurosurgeon may have staff privileges at a certain hospital to perform brain surgery, but not allowed to do other surgeries.


Getting an official permission is a long process, but once a doctor has credentials to work at the hospital, he has to provide the health care that will be reviewed by hospital committees. That is another secret of the law: peer review means a process during which doctor's colleagues discuss and evaluate his performance. It's needed to decide whether the doctor's care is safe. Whether it meets the latest standards of what a professional would do. It sounds quite good and every patient would think this information is useful and comprehensive and would count on it when selecting a doctor. However, health law allows keeping this information confidential and hidden from the public.


As it was stated by the Houston’s Fourteenth Court of Appeals, this confidentiality privilege enjoyed by doctors and hospitals hides all records and proceedings of credentialing documents and keeps them in the complete secrecy. And that is true for many states, which keep confidential all records and proceedings of peer review committee, and communications within the committee are privileged.


Therefore, each time a patient meets a doctor, he has to take a big leap of hope that this particular hospital takes credential process and peer review process seriously. Families and patients can't demand any documentation to review the past outcomes of doctors or whether the doctor had issues with patient safety in the past. In reality, public may find out about incompetent specialists only when numerous unexpected, bad outcomes are publicized through media and lawsuits.


So, when an accident happens, is a hospital responsible for anything at all? Can the hospital be responsible for credentialing a poor specialist, or for letting the incompetent doctor to work and practice medicine at that hospital?


Instead of a negligence standard used in many other cases, when a victim tries to sue a hospital for improper peer review or credentialing of a doctor, health law requires "malice". To put it simply, a patient has to plead and prove that was the hospital, which maliciously allowed that doctor to practice in the facility. And if you think that a reasonable hospital will obviously fire the incompetent doctor, you're wrong.


It's pretty difficult to prove the standard of malice. At the very least, you have to prove that the hospital had a specific intent to cause an injury to the patient. Another option is to prove that it was an omission that involved a certain degree of risk and the hospital was aware of it, but still chose to allow the doctor to practice in the facility with indifference to the safety, welfare and rights of the patient.


So, what can you do to get actual information about your doctor in the secretive environment of health care?


Almost every state has a Medical Board website, which contains profiles of the vast majority of doctors. Besides, when you get to the doctor's office, don't be shy and ask questions.


When you're seeing the doctor, ask him about his medical school, about the residency, whether or not he is board certified and how long he's been practicing in this field.


When a doctor prescribes a drug or procedure, ask about possible side effects, risks and benefits of the treatment, and also ask about any alternative treatments, their risks and benefits. You should also ask about how long a certain treatment has been around, and how long the doctor is practicing it.


Health law has given a one-sided protection to hospitals and doctors when it comes to the decision-making, but nothing prevents you from asking well-informed questions before going forward for a treatment.


Premier Credentialing Solutions, LLC has the best credentialing and licensing solutions for you and your business; We proudly offer Provider Enrollment & Physician Credentialing, Medicare – Provider Enrollment & Revalidation, Medical Licensure Services, and Full-Service Credentialing For Billers / Billing Companies. Call (800) 455-4773 for a free, no-obligation consultation.