Medical Vendor Reviews

Credentialing Definition/Introduction

Credentialing is a formal process that utilizes an established series of guidelines to ensure that patients receive the highest level of care from healthcare professionals who have undergone the most stringent scrutiny regarding their ability to practice medicine. Credentialing also assures the patient that they are being treated by providers whose qualifications, training, licensure, and ability to practice medicine are acceptable. Credentialing also ensures that all healthcare workers are held to the same standard.

Credentialing and Privileges in Healthcare

In the current era of medical practice, all healthcare institutions ensure patient safety and deliver an acceptable standard of care. While employing excellent medical staff is vital for success, the healthcare institution must have medical bylaws that define the required minimum credentialing and privileging requirements to validate the competency of healthcare providers. Only hospitals used to perform credentialing in the past, but today almost all healthcare facilities, ambulatory care centers, long-term care institutions, and even urgent care clinics perform credentialing.

Credentialing is a vital process for all healthcare institutions that must be performed to ensure that those healthcare workers who will be providing the clinical services are qualified to do so. There are ample cases reported in the literature about healthcare workers who worked in hospitals with bogus certificated and falsified experience.

Over the past 20 years, the credentialing process has become complex and onerous primarily due to expansion of the provider scope of practice, accrediting bodies, and requirements of third-party payers like Medicare, Medicaid, and private insurers.

What is New in Credentialing?

Credentialing is a vital process for healthcare institutions. In simple terms, credentialing is the process of assessing the academic qualifications and clinical practice history of a healthcare provider. Credentialing is not a novel concept and has been practiced for more than 1000 years when physicians in Persia had to demonstrate their skills and training before they were allowed to practice their art.

The process of credentialing has become more refined and thorough over the past 50 years. Today several national agencies are dedicated to maintaining the standards of credentialing for healthcare providers. The National Committee for Quality Assurance (NCQA) has established a set of standards that currently act as a guideline on how to credential health care providers. One of the key features of NCQA, as it pertains to credentialing, is to check with the primary source to verify any certificate, diploma, or degree. Simply asking the healthcare provider to submit an original diploma or degree is no longer sufficient for credentialing. Furthermore, the healthcare institution or licensing board must also check with the primary source regarding education and training. The information should also be obtained on any malpractice claims and several other factors that may have an impact on clinical practice.

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