Credentialing & Privileging

What Is Credentialing?

By Ebony Smith, CPMSM, CPCS

As a credentialing expert, I'm often approached with the question, "What exactly is credentialing?" In a recent class lecture, I was tasked with explaining my role as a credentialing expert. What is your definition of credentialing? Here’s mine:

Credentialing is a vital healthcare process that verifies the qualifications of healthcare providers to treat patients. It involves a comprehensive assessment of a healthcare professional’s history, education, training, and track record of care. As a credentialing expert, at any career level, our goal is to ensure providers meet the standard of delivering high-quality care that patients deserve. In this article, I give more context on the interrelated credentialing processes that play a vital role in maintaining the integrity of healthcare institutions.

Managed Care Credentialing

Managed care credentialing is the concept of verifying the qualifications of providers and organizations joining managed care insurance networks. To treat managed care insurance plan members, healthcare providers are required to undergo rigorous credentialing and evaluation that aligns with network requirements and needs. The managed care credentialing process benefits insurance members, healthcare providers, and the network itself by maintaining consistent, high-quality care and fostering trust among stakeholders.

For instance, consider a primary care physician applying to treat patients of a managed care insurance network. The evaluation includes more than verifying licensure and education; it includes the evaluation of quality scores in patient satisfaction and key services rendered to determine network alignment. These evaluations occur in conjunction with credentialing.

Without proper credentialing before network enrollment, all parties involved are at risk for legal scrutiny and jeopardizing patient relationships built on trust.

Medical Staff Privileging

Privileging grants clinical privileges based on providers' education and qualifications enforced by healthcare organizations. Privileging, as required by law, can only take place after credentialing. The brand of medical staff professionals (MSPs) is derived from this sector of credentialing. These professionals are known as the gateway keepers of quality patient care in hospitals, surgical centers, and more. The role of an MSP is to ensure providers, allied health professionals, and anyone treating patients are credentialed in accordance with rules and regulations set forth by the healthcare organization.

Any surgeon, such as an orthopedic surgeon, is evaluated against standard and specific qualifications related to their expertise before granting privileges. Specific requirements are included on the privilege delineation form, and privileges are selected and signed by the provider for review by the MSP.

Examples are not limited to documented cases and outcomes of certain procedures that align with the requested procedures. This information serves as proof of competency beyond education and board certification. Failure to complete a thorough evaluation of such requests can easily lead to patient harm, distrust, and — even worse — a publicly negative reputation for the organization.

Payer Enrollment

Payer enrollment is the process of assisting healthcare providers in submitting credentialing documentation and other necessary information to managed care networks to enlist as in-network providers. Payer enrollment specialists serve as liaisons between healthcare professionals and network insurance plans, ensuring a seamless partnership that promotes quality healthcare.

Consider an insured patient and their primary care physician, for example. If the patient suddenly switches insurance networks due to a job change or other reasons, their primary care physician may change depending on whether the physician is contracted with the patient’s new insurance plan. This is one primary reason why physicians express interest in joining managed care networks: to stay with their longtime patients. In this example, the provider undergoes managed care credentialing and signs a legally binding agreement attesting to providing quality care at agreed-upon rates beneficial to all parties, among many other obligations. It is important to note that providers who are not in an insurance network are not permitted to treat insured patients. Thus, treating insured patients as a non-contracted provider is a greater expense for both the patient and provider.

The Legal Importance of Credentialing

Credentialing is not just a best practice — it is a legal requirement by state and federal laws. When states and federal programs enact or amend their regulations, healthcare organizations and providers must interpret these changes into the policies and guidelines of their practice. State and federal healthcare regulatory programs were formed to protect provisions against discrimination, cost-effectiveness, and efficiency. Healthcare organizations and providers must comply with the guidelines developed as a healthcare provider or face criminal and civil penalties, including prison time.

The support from state and federal regulatory agencies emphasizes the importance of quality credentialing as it aids in minimizing harm to patients by filtering out incompetent and unqualified providers and organizations. In legal context, credentialing is the gateway to high-level quality healthcare services for all. It protects the patient from harm and providers from legal risks.

Tying It All Together

Credentialing is a critical procedure that goes beyond verifications and encompasses a comprehensive assessment of providers, serving as a key element to quality patient care. Experts in managed care credentialing, privileging, and payer enrollment are gatekeepers of quality, safe, and efficient healthcare. Therefore, you should never miss an opportunity to thank credentialing experts for their service, knowledge, compassion, and commitment to the healthcare industry.