Below is a very brief introduction of what credentialing really is and why it exists. Many people believe that once you graduate from school or start your business, you will make money. That is not the case.
In ancient Persia the physicians of the time would be tested before they were considered qualified enough to practice medicine. Three heretics were treated and if they survived then the physician was deemed a competent medical professional.
In today’s era however, we depend on records of education and training, residencies, licenses, specialty certificates, and the career history of a physician in order to grant privileges to practice. This is not only true to legally posses the rights to practice in your state, but also to be authorized by individual insurance companies to see their patients. All of these processes in sum are known as credentialing. Through credentialing we maintain the high standards of safety and professionalism that is expected in the healthcare community. This also reassures patients that the care they are getting is provided by a competent physician.
Healthcare institutions, such as CMS, private insurance companies, and state licensure regulators have mandates in place to determine the documentation needed before providers can begin to deliver services. This ensures that an individual or entity is qualified for the role they are seeking is vital to maintaining quality patient care.
Credentialing has become a complex process that can take a large amount of time. The authenticity of degrees, licenses, and certificates must be verified from primary sources. This is a standard set forth by The National Committee for Quality Assurance (NCQA) as a guideline for the credentialing process. Even if you are a licensed healthcare worker, who has been permitted by law to provide care without supervision or direction within the scope of your license, you must still go through the credentialing process with payors before you can bill for services.
Additionally, healthcare workers are limited on the types of clinical services they provide. Privileges are granted based on qualifications and training in order to determine the scope of the physician’s practice. Scope of practice is determined not only by training, but by facilities and the willingness of malpractice insurance companies to cover an entity for service. A healthcare worker must be authorized before performing a specific set of services. For example, primary care providers and surgeons will have vastly different privileges based on their credentials and licenses. This also has significant implications with regard to reimbursement.
There are several organizations that verify primary sources for credentials. These often vary by provider type. For example, The National Practitioner Data Bank, a US Government program, can provide information on malpractice cases, awards, loss of privileges, and suspension of licenses. For nurses, certifications can be verified through the American Association of Nurse Practitioners and the American Nurses Credentialing Center. There are also many other organizations such as NPPES, CAQH, AHCA, and PECOS that are all involved in the credentialing process in various ways. The specific organizations involved depends on the goals of the individual provider and what they are trying to achieve.
We can help you succeed.
Needless to say, the process of credentialing can be an arduous and convoluted process. It can feel like a tremendous hurdle and be discouraging for many providers. North Florida Credentialing is here to help. We can help you strategize a plan to achieve your goals as quickly as possible. We understand the healthcare system and the confusion created by payors. If you have any questions, please feel free to contact us today. We place the success of providers over profits and do everything we can to help you succeed.
