Healthcare Credentialing Issues, a Breakdown

Credentialing usually involves gathering information about the physician’s background and qualifications by a formal application that is then verified against information available from reliable sources like the National Practitioner Data Bank or the American Board of Medical Specialties. Practice problems may be identified by contact with any state where the doctor has an active license. Proof of education and training is usually verified through direct contact with schools and hospital programs, and registration with the Drug Enforcement Agency is usually confirmed. Other relevant information includes Medicare/Medicaid registration

Time Frames for Applications

It’s important to allow adequate time for credentialing if the provider is new to an area. Most credentialing is accomplished within 120 days, but it’s good to allow at least 150 to 180 days to complete the process. Any deficiencies in your application, including missing, outdated, or incomplete information, will delay the process. The areas that most commonly delay completion of credentialing include work history, current work status, malpractice coverage, hospital privileges, peer references, and attestations.

What Information to Include

Some information required for credentialing in a variety of situations includes personal information, like credit history or personal bankruptcy. This information may reveal a malpractice claim paid out of pocket and unreported to the data bank. Even gaps in employment are the subject of investigation and must be thoroughly explained in most cases. Because healthcare facilities may become liable in malpractice suits if they have allowed incompetent physicians to remain on staff, they gather all information possible to inform their decision.

The push for rigorous credentialing began in the 1970’s, with the Joint Commission on Accreditation of Healthcare Organization (now TJC.) With a number of high-profile cases resulting from claims of failure to properly credential medical staff, it appears this trend will continue unabated.

An excerpt by Honor Ashbaugh, MD, published May 12, 2015; edited by P Whitmarsh, July 17, 2018.

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