A starter’s guide to physician credentialing

Protect your patients and your organization by verifying applicants.

Entrusting a loved one into another’s care is one of the hardest decisions a family can face. Family members often find themselves overwhelmed by guilt, fear or anxiety during the transition to long-term care. Hiring capable physicians to provide the best care for your patients helps alleviate these concerns and brings family members some peace of mind.

Credentialing is the process of verifying and evaluating the background, education and licensing of physicians applying for privileges within your healthcare organization. It is an involved but crucial process that helps ensure only the most qualified medical professionals practice at your healthcare facility.

From providing appropriate care to protecting your reputation, credentialing allows your organization to operate safely and effectively.

3 Reasons for Credentialing

Patient Safety

You’re in the business of helping others. First and foremost, the care of your patients, their safety and wellbeing are your greatest responsibilities and top priority. Failing to properly verify a physician’s credentials before granting them privileges puts your patients at risk.

Liability

When the unthinkable happens, a well-documented credentialing process can help your organization defend itself against claims of negligence. In cases of negligent credentialing, some states require organizations to prove every preventable measure was taken before a physician was granted privileges.

Fulfilling Legal Requirements

Depending upon your state and the nature of your facility, there may be legal standards for credentialing that your organization needs to uphold. It’s always better to go above and beyond these standards and the minimum requirements set by The Joint Commission.

Putting the Process in Place

Even before you can begin accepting applications or pre-applications, the credentialing process for your organization must be established. Create a written policy stating the process you’ll use, including the information applicants will need to provide. Here is a list of standard information to request:

• Current license
• Current CDS and/or DEA registration
• Evidence of relevant training, experience and competence
• Professional experience and affiliations
• Current certificate of insurance
• Malpractice/Claims history, if applicable
• Applicable board certification information

All of the above documents will need primary source verification – which is the confirmation from the issuing organization that they are correct and up-to-date. This can be done through direct correspondence, a telephone conversation or online communications.

In addition to these, you will also want to consider the applicant’s current health, professional references and criminal history.

After identifying the information that needs to be verified, you’ll need to set up the process to do so. First, you’ll need to form two groups: a governing body and a credentialing committee. The governing body is responsible for the actual verification process and its documentation, while the committee reviews completed applications and the verified information. In other words, the committee makes the final decision over whether or not to grant a physician privileges, and the governing body provides the information that the committee needs to make that decision.

Consistency is Key

In addition to the overarching credentialing policy, your organization should have standards by which they accept or reject applications documented as well. Writing the determining criteria sets a standard of consistency that can help your credentialing committee when facing difficult decisions and can help your organization avoid discrimination claims from rejected applicants.

Policies are only good if they are consistently followed. Many organizations rely on third party vendors to ensure that primary source verification is completed in a consistent manner. If you are considering a third party, be sure that they are a certified credentials verification organization (CVO). Not all background check companies are CVOs, so double check before using their services.

After verification is complete, all relating documents need to be consistently filed and organized. This will help your organization in the event of an audit or negligence claim.

Risk Indicators

During the credentialing process, your goal is to weed out potential risks. Here are some red flags to look for:

• Applicant is reluctant to provide all required documentation
• Professional references only provide vague descriptions of the applicant
• Sudden loss of privileges or license
• Gaps in clinical practice or insurance coverage
• Short tenures at multiple organizations
• History of substance abuse, domestic violence or misconduct
• History of investigations or unusually high number of malpractice claims

If an applicant’s history reveals any of these warning signs, there are several actions your organization can take. Depending on the level of severity, a follow up interview could clarify information, or a more formal investigation may be needed. Either way, notify the candidate of how you intend to proceed.

Reviews and Reappointments

A lot can happen in two years. A physician’s health can deteriorate, malpractice claims can be made, or the physician can fail to maintain the requirements set by your organization. That’s why it’s important to require acting physicians to reapply for privileges every two years.

With the shortage of medical professionals and the increasing demand for long-term and geriatric care, some organizations might be tempted to cut corners in the recruitment process. However, facilities that neglect to properly credential physicians do so at a huge risk to the safety of their patients, their reputation and their bottom line.