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.