Credentialing is the process of obtaining information, verifying the information, and evaluating physician applicants who want to obtain or renew their privileges at a given healthcare entity. The process should include verification of licensure, education, medical training, certification (if applicable), malpractice history and professional experience.
Credentialing starts with a completed application. That information then needs to be verified. For certain items, verification should be obtained from the “primary source” or originator of the credentials to determine if it is real, current and complete. For example, a physician license would be verified by contacting the state medical board it was issued by, and asking them to verify that the license is current, and if any actions such as suspensions or restrictions have been issued by them against the individual. Obtaining a photocopy of the license directly from the physician is not adequate. Methods of primary source verification include direct correspondence, telephone verification, internet verification, and reports from credentials verification organizations.
The process of primary source verification can be done within the organization or externally. Many state medical boards provide primary source verification for education and training, as well as license. The American Medical Association (AMA) also offers a profile service for initial and reappointment credentialing. If an outside agency is utilized, it should be by a certified credentials verification organization (CVO).
The final step is a review of the verified information to identify any potential concerns such as missing or inaccurate information, unexplained gaps in time, inadequate references, or significant medical malpractice history. The information can be reviewed by a designated Credentials Committee set up specifically for physician review, or by key individuals within the organization who may be responsible for physician oversight. This might include the Medical Director, Executive Director and Board Member.
There is no single prescribed method for performing credentialing and privileging. Most accrediting bodies, and some state licensing authorities, have developed standards or recommendations in this area, however, including The Joint Commission and The American Academy of Hospice & Palliative Medicine (AAHPM).
What should a complete physician file include?
Physician files should be at least as complete as those files kept on the organization’s employees, even if the physicians are contracted to provide service. Each file should include at a minimum:
- A completed application
- Attestation questions related to:
– Challenges to any licensure or registration
–Relinquishment of license or registration
–Termination of medical staff membership
–Limitation, reduction or loss of clinical privileges
–Health status
–Criminal history
- Current license*
- Current CDS and/or DEA registration*
- Evidence of relevant training, experience and competence*
- Professional experience and affiliations*
- Current certificate of insurance*
- Malpractice/Claims History, if applicable*
- Applicable board certification information*
- Professionalrecommendations
* Requires Primary Source Verification
Why should we credential physicians?
The most obvious reason for physician credentialing is to assure that a physician applying for privileges at your organization has the appropriate education and experience to work with your given patient population. A second reason is to assure that the information provided on the application is complete and accurate. This should be as true for physicians who are employed or contracted by your organization as it would be for any employee. But the most important reason for credentialing of professional healthcare providers is to assure quality patient care. If done correctly and comprehensively, credentialing ensures that patients receive quality medical care from qualified practitioners.
In many states, a claim of negligent credentialing can be asserted against a healthcare organization that does not properly credential a physician. Claimants bring this type of action alleging they have been harmed by a practitioner who they claim was not qualified to perform the services. This type of suit is premised on the fact that the health care organization should have discovered that the physician was not qualified during the credentialing and privileging process.
What needs to be done on an ongoing basis?
Credentialing should not be a static process. Administrative policy should indicate the required frequency for re-credentialing of physicians, generally every two to three years. During that time, however, a diary should be set up to assure that the organization maintains current information regarding licensure, certification, DEA registration, and malpractice insurance coverage.
Re-credentialing offers an opportunity to evaluate a physician’s practice within your organization over time. As with any professional employee, it would not be appropriate to hire or contract with someone to provide medical services and then not monitor their performance. An important component of any re-credentialing process is ongoing quality assurance and peer review activities.
In summary, negligent or inadequate credentialing is a significant risk exposure. It is important that all healthcare organizations establish a consistent process for credentials verification of all professional staff, including physicians.
