In healthcare, Physician Credentialing is the process of organizing and verifying a doctor’s professional records. This includes their board certifications, hospital admitting privileges, education, insurance, professional references, work history, and more. It’s a vital safeguard for patient safety and risk management.

When a doctor applies for admitting privileges in a hospital or applies to join a practice, they give permission for that organization and/or their credentialing provider to research the physician’s background, education, and professional certifications. A physician has to be credentialed for every procedure they perform and any special equipment they will use in those procedures.

The point of physician credentialing is to verify the accuracy of the information the doctor has included on their application. For some information, the practice, hospital or credentialing provider will perform Primary Source Verification – for instance, contacting the medical school to verify that the doctor did indeed attend the school and graduate with the stated medical degree.

The Affordable Care Act has substantially increased physician credentialing requirements for Medicare and Medicaid enrollment in an effort to reduce fraud and abuse. Now physician credentialing is required by the federal government, each state government and each accreditation agency.

For Physicians, it’s important to start the credentialing process as early as possible, as it can take anywhere from 90 – 180 days. As payer organizations have grown into major companies, the ability to expedite an application is long past and each payer has its own internal timeline for application processing.


Tips for speeding up physician credentialing

A majority of physician credentialing applications have missing, outdated or incomplete information, which can cause significant delays in credentialing. The most overlooked data are work history and current work status; malpractice insurance; hospital privileges; and attestations.   

Most payers in the U.S. have adopted the uniform credentialing program of The Coalition for Affordable Quality Healthcare (CAQH). Physicians who keep their information up to date with CAQH have fewer delays in credentialing and re-credentialing.

Physicians should know their state’s regulations regarding credentialing. Several have reciprocity regulations, meaning if a physician is credentialed in one state by a payer, their credentialing in another state for that same payer can be streamlined. Additionally, a physician moving from one practice to another within the same state may not have to go through the full credentialing process again.

Hospital credentialing can no longer be used for a physician’s practice. It was commonplace years ago, but now each healthcare organization must conduct its own credentialing.

Consider outsourcing credentialing, as the workload is enormous – hospitals have entire departments dedicated to it. If a healthcare practice falls behind in the credentialing, their insurance reimbursements will be slowed.

Speak with Advantum Health about outsourcing your physician credentialing.