Physician credentialing is often one of the more onerous duties in hospital administration, but it is vital to the institution’s operations and business. The physician credentialing process ensures that health care providers are certified to provide the services required by the hospital. While some providers see it as a troublesome paperwork exercise, it is, in fact, insurance on the hospital’s part that those who are employed in patient care have proven that the utmost standards of care will be practiced on a daily basis.

Keeping records is not glamorous work but it is essential. Attention to detail and making sure that all the paperwork is in order and up to date means that physician credentialing professionals need to stay on top of timelines and deadlines and be cognizant of the requirements of various medical specialties. Continuing education units need to be tracked and filed, board certifications need to be verified, and physicians, who are often focused on treating patients, need to be reminded when requirements are due.

Beyond making certain that physician credentials are updated with state agencies and governing bodies, physician credentialing staff ensure that physicians are credentialed with insurers and other third party payers. The Medicare and Medicaid programs require applications to be filed and updated before physicians can treat these beneficiaries for reimbursement. New physicians looking for employment need to be checked against a CMS’s Disqualified Provider List to guarantee that they are allowed to be employed by the hospital. The penalties for allowing a disqualified provider to treat patients are severe and a hospital cannot afford to be negligent in this matter.

Besides federal and state health care programs, the private insurance market has its own requirements. Each insurance company has its own standards for participating in the plans it offers. Proof of education, experience, malpractice coverage, and legal history needs to be submitted to each commercial insurer according to their set standards and format. Physicians who are not enrolled in commercial insurance plans are considered out of that plan’s network and patients will receive reduced benefits or not be covered at all for received services. This is a drag on the hospital’s revenue stream and can influence patients’ decisions on where they receive their care.

Physician credentialing is a multi-faceted process that entails maintaining and updating documentation regarding a physician’s current qualifications. It is not something that can be neglected. It needs to be performed by trained professionals who understand the process and its value not only to each individual health care provider to the larger institution as a whole.