Elements of the Credentialing Process

Group practices of all sizes should ensure that each physician within the group is fully credentialed, trained, and experienced to practice in his or her designated area of medicine.

Certification should be provided by reputable organizations and institutions; a document that lists a physician as a "specialist" in a certain area is only as good as the organization that provided the certificate. It may be necessary to research an organization or institution to become familiar with its credibility and standing.

The steps for credentialing a new member of the healthcare team should be formalized in a written policy. It should be conducted by persons whose job descriptions and areas of accountability within the practice attest to the need for their participation/oversight of the various steps that need to be taken. Each phase of the process should be documented and the resultant files should be retained with each individual's employment file.

Elements of the physician credentialing process may include, but are not limited to the following:

• Education and experience history (e.g., residency programs, additional studies).
• Evaluations and professional references.
• Licenses: Including alternative and complementary credentialing licenses, if applicable. Verification of professional standing generally requires originals of documents as a means of preventing alterations or forgeries.
• Board certification status.
• Prior affiliations, complete work history, including explanations for gaps.
• Malpractice claims history and proof of insurance.
• Certifications by licensing boards.
• Verification of US citizenship or approved work status.
• Proof of compliance with corporate policy that credentials must be periodically updated. For example, the National Committee on Quality Assurance (NCQA) requires a credentialing update at least every three years.

Source:  "Protector"--Medical Protective

The Joint Commission (JCAHO) requires bi-annual updates. While these organizations don't dictate credentialing standards for office-based providers, they do set a tone for professionalism and an expectation for oversight that all healthcare professionals should be aware of and seek to emulate.

Maintenance in each individual's human resource file (or professional documents file) reflecting that all training, in-service, and continuing education (especially that necessary for maintenance of a license, specialty status, or certification) is up-to-date.

Reporting adverse actions, including:

• Malpractice history.
• Discipline actions, dismissals from programs, schools, residencies, associations, exclusion as a Medicare provider, etc.
• Compliance or HIPAA actions.
• Criminal background checks.
• Pre-employment (or employee random) drug testing as permitted/required by state law, licensure regulations, or organizational policy.
• Triggers for further investigation: a "fill-in-the-blanks" process when gaps appear in the employment history, insurance coverage, or educational progression; vaguely-worded reference letters; inability to produce originals of documents (e.g., licenses, diplomas, etc.).

Regardless of the size of the medical practice, the credentialing process should be a formalized part of the organization's policies and procedures. Numerous resources and formats are available through local hospitals, peer review and human resources experts, and through professional medical associations.

Comments

[Kathy Levesque]

Readers looking for useful information and guidance on healthcare credentialing practices could visit our site at www.online-crc.com (the Credentialing Resource Center).