In the healthcare industry, Credentialing is a vital function that ensures patients receive safe and competent care, supports the World Health Organization’s model of care as mandated by regulatory organizations, and reassures physicians and other providers that they are working with trustworthy, competent colleagues. The Credentialing process occurs behind the scenes, but is critical to ensuring that health care organizations employ only qualified, licensed (or registered), and competently trained health care professionals to deliver care to their patients. At MGSI, we view the Credentialing process as not only an administrative function, but also the basis for delivering quality care and ensuring operational excellence.
Credentialing is a systematic process to verify a healthcare provider’s qualifications before that provider can provide patient care and be able to bill for that care through insurance networks. This verification verifies the educational training, licensure, previous board certifications, work history, and professional references of that provider. The purpose of Credentialing is simple but very important – to ensure that each person providing care meets the required standard of competence and professionalism, which is established and maintained by the health care organisation.
Credentialing applies to all healthcare professionals including physicians, nurse practitioners, allied health professionals, and behavioral health providers. Credentialing enables health care organizations to confirm that the individual is legally authorized to practice in that community and clinically qualified to provide care. Lack of proper Credentialing creates risk for the organisation to be out of compliance with regulatory requirements, to lose out on insurance reimbursement, and creates most importantly an increased risk to the safety of patients receiving services from that organisation.
The Importance of Credentialing
Credentialing is not just a formality. It affects how trustworthy a patient will view the organization and their providers, as well as the overall reputation of the organization, and its stability in terms of finances. Patients have an expectation that when they seek healthcare services from any organization, that provider will be properly credentialed and qualified. Credentialing serves as the verification of these credentials.
Credentialing for regulatory purposes related to Healthcare organizations is the process of ensuring compliance with the requirements outlined by the regulatory organization (such as CMS), State medical boards, and accreditation agencies. If a healthcare organization cannot maintain their credentialing records accurately, they may become subject to audit/penalty/loss of accreditation.
From the financial aspect, credentialing is also the means by which you obtain a network agreement for payers. Insurance companies will not reimburse claims unless your providers are credentialed and registered appropriately. If you have delays or inaccuracies in the credentialing process, your cash flow can be adversely impacted and, ultimately, your revenue cycle.
The Steps Involved in Credentialing
The credentialing process for healthcare is comprised of several important steps:
Collection of an Application.
The collection of the application is the first step in obtaining full details of a provider, including education, training, licensure, certification, and work history.
The next step is to verify that the information provided is accurate. A Primary Source Verification (PSV) is the process of independently verifying the credentials of a provider by obtaining the verifications directly from the source of credentialing (e.g., Medical Schools, State Medical Boards, Certifying Entities) to confirm that each credential is accurate and legitimate.
Thirdly, a background check should be performed to identify any potential risks to the organization or the patient(s) through the presence of malpractice claims, disciplinary actions, exclusions or sanctions against a provider.
The concepts of credentialing and privileging, while often discussed in conjunction with one another, are two completely distinct processes. The verification of a provider’s education and training (credentialing) proves that they are qualified to perform certain types of work, while privileging represents the determination of what specific services are being authorized by that provider (e.g. surgeries, etc.) at a facility.
One of the largest changes about technology in the credentialing space is the introduction of the cloud-based credentialing systems that allow for the secure storage and dissemination of documents, as well as the ability to utilize standardized/documented workflows to streamline the credentialing process. The automation of reminders to providers to complete their credentialing process in a more timely manner due to regulatory updates has aided organizations in maintaining a complete and accurate credentialing file for every provider.
MGSI combines modern technology with the knowledge and expertise of credentialing professionals to assist organizations in increasing the efficiency of the credentialing process while maintaining the required attention to detail that is paramount in the Healthcare industry.
As a referral agency, MGSI focuses on helping organizations quickly bring onboard providers and continues to support organizational success. Our credentialing services give hospitals, clinics, group practices, and healthcare networks a tailored approach to credential their providers quickly and effectively.
Utilizing MGSI for credentialing provides organizations with dedicated personnel who stay up to date on regulatory changes and payer requirements. This allows internal staff to devote time and resources to better serve patient needs and provide opportunities for strategic growth instead of focusing on paperwork and following up with credentialing processes.
From a broader perspective, credentialing is about protecting patients and developing trust. Credentialing helps ensure a qualified and qualified professional delivery care. Credentialing also complies with industry standards and protects an organization’s financial stability.
Credentialing will remain an integral component of any healthcare organization in the future. Partnering with an organization like MGSI allows healthcare organizations to convert the complex administrative nature of credentialing into a systematic, dependable, and streamlined process to ensure the success of that organization in the long term.