What is Credentialing?
Credentialing is a term that usually encompasses two separate processes: credentialing and privileging.
- Credentialing: Primary source verification of a health care practitioner’s education, training, work experience, license, etc.
- Privileging: Granting approval for an individual to perform a specific procedure or specific set of procedures based on competence in the specialty in which privileges are requested.
- Insurance Payor Enrollment: This process generally applies to practitioner who will be employees of CRMC. By completing this process, it ensures the practitioner is enrolled with Medicare, Medicaid and applicable third-party payers so that CRMC can bill and be reimbursed for care, treatment or services provided. Please note that the rules and systems used to complete provider enrollment varies across health plans.
Who is Credentialed?
Practitioners who are independently responsible for patient care at CRMC by virtue of their license and hospital authority must be credentialed (regardless of whether they are CRMC employees or not). Credentialed providers at CRMC include:
- Advanced Practice Providers
Why does CRMC Credential?
CRMC, like other health care organizations, is legally responsible for knowing that individuals providing patient care are qualified and competent to do so. The Joint Commission, The Centers for Medicare and Medicaid Services (CMS), Minnesota Department of Health and Human Services and other oversight organizations require that members of the medical and allied health staff be credentialed and privileged before working in the facility.
No. It is CRMC’s legal obligation to ensure that all practitioners have gone through the credentialing process and have been approved by the Governing Board to work at CRMC. A practitioner working at CRMC before the credentialing process is complete places the hospital and the practitioner at legal risk and can directly impact CRMC’s accreditation status.
What is Primary Source Verification (PSV)?
- PSV is the process of verifying credentials directly with the source. For example, a credentialing office cannot accept a copy of a medical school degree as evidence that the physician graduated from medical school. The school must be contacted directly to verify the physician’s attendance and graduation.
- PSV is required so that hospitals and credentialing offices do not receive fraudulent documents from applicants or other non-primary sources.
- A credentialing office cannot accept any verification that comes through a third party rather than the primary source.
- PSV is a requirement by accrediting bodies as well as the cornerstone of a good credentialing process.
What is The Joint Commission?
- The Joint Commission is an accrediting organization with a mission to improve the safety and quality of care provided to the public.
- Hospitals voluntarily submit to The Joint Commission accreditation surveys every three years; the survey is a comprehensive evaluation of the overall quality and safety of the organization.
- CRMC Provider Credentialing Services complies with all of The Joint Commission credentialing standards.
Most health care organizations advise submitting an application 90-180 days before a practitioner’s start date. Ninety days is a benchmark because it allows extra time when verification sources do not respond in a timely manner or clarification of discrepancies is required. You will receive an online application portal login from Symplr when it is time to start the process along with a welcome email from the Medical Staff Office.
How long does it take for a practitioner’s application to go through the credentialing process?
- The Credentialing process consists of two steps:
- Verification and evaluation processes performed by the Medical Staff Coordinator/Credentialing Specialist, Payer enrollment and approvals; and
- Review and approval of the verified application by the CRMC Credentialing Committee, Medical Executive Committee and the Governing Board of Directors
- Offices that perform primary source verification of credentialing applications have very little control over process time. The process time is affected by outside verification sources (other hospitals, training programs, peer references, employers, etc.) responding to requests for information.
- An application and verification process can be completed in less time if peer references and other verification sources promptly respond to CRMC’s requests for information, requested documentation is supplied by the applicant in a timely fashion and there are no red flags identified in the application process which require further investigation. If a response is not received, credentialing staff executes additional requests to sources; this causes a significant time delay in completing the process.
Elements that must be verified:
- Medical school, internship, residency and fellowship
- License, DEA, Board Certifications, malpractice insurance
- Past and present jobs (including moonlighting) and hospital affiliations
- References must be colleagues that can attest to the applicant's clinical competency that have worked with the applicant in the past 12 months and have the same degree or higher
- Office of Inspector General and Government Security Agency
- Background check
- Medicare Opt Out
- National Practitioner Databank
- Gaps in employment or education over 90 days
- Any other items requested by the Credentials Committee after review (such as additional references or a background check, etc.)
All items provided with the application are reviewed to ensure they match the above verifications. For example, the AMA profile is compared to the application data. This may help fill in gaps or may lead to requesting explanations of discrepancies.
Any time an item is missing delays occur as the verifications cannot be completed.
Let's proceed as if the application is complete from here.
At this point the verifications are queried and references and affiliations are requested
The applicant's signatures are good for 120 days. Most files are complete within this time frame but if not second signatures are required. The signatures are releases and attestations that the information submitted is true and accurate.
- 90 to 120 days to process verifications and request missing elements
- 30 days for chair evaluation
- 30 days for review by Credentials Committee, Medical
- Executive Committee and the Board
Most frequent reasons for delays:
- Incomplete applications (not all questions answered) Missing attachments
- Missing data such as email addresses for references
- Pending MN license or DEA
- Discrepancies or gaps in employment not explained
- Malpractice case data not provided
- References that do not reply
- Names changes – need to match license always
To gain a better understanding of the reasons for the current credentialing process read The Blind Eye by James Stewart. This is the true story of Michael Swango. His case led to the formation of the National Practitioner Data Bank in 1990.
You will receive an email from firstname.lastname@example.org with your login information to complete and return along with applicable forms 90-120 days prior to your appointment expiration date. Application are due back within 30 days.