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The Physician Credentialing Process From A to Z

physician credentialing in the processPhysician credentialing is a necessary step for all doctors founding or entering a practice, and should be started well in advance of going to work. It can actually take up to a year to credential a physician. The process first requires hospital privileges, meaning that a physician must have a license and proof of malpractice insurance. Then the credentialing begins.

Hiring and scheduling a doctor in the process of physician credentialing bogs down the individual and the practice; it can complicate patient scheduling and delay or halt payment altogether. Therefore, credentialing should be started as soon as possible and kept on schedule by a designed system set up by the individual clinic.

While there is not a universal system for how to credential a physician, we recommend utilizing the following physician credentialing checklist:

  1. Weed Out Potential Applicants – When filling a medical team position in your group, some of the first items you verify for potential candidates are training, education, and prior experience claims.
  2. Affirm Contact Information – The next step is to make solid contact with the one or two physicians which may come on board, affirming correct contact information. They may prefer contact through a current office manager or nurse. Knowing if the applicants have regularly updated with CAQH (Coalition for Affordable Quality Healthcare) will also make the process that much easier.
  3. Follow Instructions for Information Carefully – Each state has different regulations and providers have slightly different requirements. Touching base in advance and being familiar with these makes the process of collecting the required documents go more smoothly. Giving out clear instructions to your physician candidate on what information to send and when is equally important.
  4. Verify Privileges – As mentioned above, being licensed in the state and checking for malpractice insurance are essential before moving forward. Based on experience and qualifications, a physician may also request specific privileges to perform surgery or give unique types of care that require additional verification.
  5. Perform a Background Check – A background check is usually the most time-consuming aspect of the process of physician credentialing. Every piece of information given must be checked for accuracy and truthfulness via phone calls, emails, and database research. This includes querying the National Practitioner Data Bank for closed and settled claims history, as well as reviewing employment history and any time gaps.
  6. Gather Peer References – It’s standard to require three peer references by physicians of the same specialty who have no relation to the applicant and are not from the same practice. This is the best way to get an idea of the character of the physician prior to direct observation.
  7. Investigate Malpractice Claims – In review of the claims history with the NPB (National Practitioner Bank) and the malpractice carrier, you might find settlements and closed lawsuits. This does not automatically mean the physician shouldn’t be hired. Instead, make sure the applicant fills out a section to explain the history.
  8. Send Application for Review – Finally, all that is left is sending the application to the practice’s governing board, which may only meet a few times each year. If there are concerns or red flags, the board may elect to proctor the physician for a few months (i.e. have him/her shadowed by a physician of the same specialty).

Remember, every plan is different but each one eats up hours of staff time on the phone and filling out applications. One suggestion is to make copies of all important forms along the way, and to request a return receipt when documents are mailed/faxed to the appropriate parties. This ensures and proves that materials are received. It’s just one way to follow-up on the process and instigate a quicker turn-around.

The credentialing process can be a tedious and lengthy process, but don’t let it become a detriment to your healthcare clinic! One way to ensure that the process is handled quickly and accurately is to hire out to a third party. Billing Advantage is one such company that not only handles the medical billing process but can also assist with other health care management tasks. For more information on how Billing Advantage can help organization, productivity, and revenue, read about our expert credentialing services.


Donna Whipple Donna Whipple

Donna Whipple, Psy.D. is a clinical psychologist with over 30 years of management experience. She has particular interest and expertise in HIPAA and ethical treatment and business practices in a changing high tech industry. She has a particular talent in boiling down complex regulations so providers can understand and comply with them. As co-owner of Billing Advantage Inc., Donna is involved in all aspects of the company but her particular contributions to the business is in mentoring upper level managers and helping them be more effective in their leadership.


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