Physician Credentialing is an important process of verifying and evaluating a physician or medical records. This usually includes hospital privileges, physician credentials, malpractice protection, patient care reporting, academic credentials, insurance coverage, professional liability, and many others. It is an essential safeguard for risk management and patient protection. In this article, we discuss physician credentialing and how to choose from different options to protect yourself.
One of the primary considerations in physician credentialing is hospital privileges. Hospitals are extensive networks that require verification of prior authorization. As such, they are often the first stop for any claims, disputes, or questions a patient may have. For this reason, it is critical to stay on top of hospital privileges if you are working with any hospital or healthcare provider. There are specific steps hospitals take to verify prior authorization, including verifying documentation and physician contact information.
Another step in physician credentialing is to verify any educational qualification a physician has acquired. For most states, a physician must hold a medical school degree or be in good standing with a university. This is verification that is required to prevent credentialing risks. Many healthcare providers choose to self-certify, but this is not advisable for several reasons. While it is possible to work around state regulations, healthcare employers will typically not accept an employee simply because they took time to earn their degree or go to a great college.
Physicians also need to have access to the latest medical knowledge. For this, they will need to interact with healthcare providers. To do this, they must maintain contact with their current physicians. Some doctors and other professionals encourage their current patients to keep them in the loop on their health status. This helps patients connect with physicians who care about them and know what is going on with their bodies. This personal connection helps patients feel connected to the physician as someone they can trust instead of just an unknown number.
In addition to interacting with patients, physicians should be connected with the latest information on local, regional, national, and international laws and regulations. They should perform annual verification, which is required by law for all healthcare facilities. This verification process helps ensure no fraud or false claims when submitting claims to insurance and government agencies. It helps ensure that government agencies can accurately determine the value of claims and help cut down on the amount of time that is wasted due to litigation and appeals. Verification helps cut down on the cost of having to pay out for fraudulent or false treatments.
Along with checking out a physician’s credentials, healthcare workers like pharmacies, doctors, nurses, and even emergency room staff should also undergo verification. By performing background checks on these employees, hospitals and other institutions protect themselves from employees with a criminal record, substance abuse, or bankruptcy. In addition, doing background checks can help prevent fraud in the treatment of patients. These can also catch fraudulent practitioners trying to take advantage of patients who really need extra medical attention.
Another key benefit of verifying physicians is protecting the integrity of the healthcare system. The National Practitioner Data Bank (NPDB) and the National Health Information Center (HINC) keeps records on all physician contacts made by healthcare workers, patients, and other individuals. In doing this, hospitals and other institutions can determine whether to hire a physician, consider a new one to watch out for, or decline a new patient based on their past.
Currently, several online tools help facilitate the entire physician credentialing process. Most allow for multiple inputs from physicians and other key stakeholders. For example, NPDB and HINC allow for the submission of a smart sheet. This smart sheet can include data such as a physician’s current license status, specialties, certifications and fellowship information, complaints, reviews, and more. When physicians use the smart sheets, they can add their contact information, specify which healthcare providers they work with, and add notes about each provider. They can also specify which data will be entered and how it will be presented.