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Credentialing is Crucial to Healthcare Providers; Here’s Why

Truth is, many patients know little more about their physician’s qualifications than what they see neatly hanging from their office wall. While they’re able to access in-depth background information about their mechanic, it’s when they are at their most vulnerable, entrusting their family’s health to a qualified healthcare professional, is when they must hope that there’s more than meets the eye behind the sometimes bewildering abbreviations spread across those medical school diplomas.

That’s why medical credentialing exists. 

Put simply, medical credentialing is a process by which medical organizations verify the credentials of healthcare providers to ensure they have the required licenses, certification and skills to properly care for patients. It’s an essential function for hospitals and others which precedes hiring or obtaining coverage by an insurance carrier. However, the procedure is anything but simple, as we’ll soon discover.

Why is credentialing so important?

It might seem, at first glance, like credentialing is simply a paperwork chore, rather tedious and not nearly as essential as patient care, but it’s an undertaking (with an urgency) that can’t be taken lightly.

Medical credentialing provides quality assurance to the medical industry, which benefits everyone involved. Not only does it guard hospitals and other organizations from would-be lawsuits, it’s a safeguard put in place to protect patients by supplying competent, high-quality healthcare providers.

More to the point, hospitals and clinics can be assured that the staff they hire will provide care at the standards demanded from them. Plus, insurance companies have an incentive to keep costs down and therefore prefer to insure only those medical providers who demonstrate sufficient competence in practicing medicine.

Medical practitioners benefit from credentialing because once they receive privileges to accept clients from insurance companies, they can grow the number of patients who have access to them.

Finally, medical credentialing is perhaps most important because it’s the one method that permits patients to place their trust with utmost confidence in their chosen healthcare provider(s). Through a standardized process involving data collection, primary source verification and committee review by health insurance plans, hospitals and other healthcare agencies, patients are confident in their healthcare professional’s ability and experience.

Bottom line: The healthcare provider credentialing process works to make sure that everyone from doctor to patient, and everyone in between, is better off.

A bit of credentialing history

While most of us might think of medical credentialing as a present-day concept, it’s been a part of physicians’ livelihoods dating as far back as 1000 BC, at least in some rudimentary form. In ancient Persia, to qualify for licensure, a physician had to treat three heretics – if they lived, that qualified the physician to practice medicine for the rest of their natural lives. Sound simple enough?

By the medieval period, the credentialing process was becoming be more elaborate. In 13th century Paris, the College de Saint Come divided the barber surgeons (surgeons of the long robe) from lay barbers (barbers of the short robe). To become a member of the College, and therefore a surgeon of the long robe, one had to meet specific prerequisites for admission and pass an exam given by a panel of surgeons.

Fast forwarding to the U.S in the 1960’s, the Darlington v. Charleston Community Memorial Hospital case established the duty of hospitals to verify their physician and other provider competencies. This landmark suit soon brought about the creation of a credentialing process as hospitals and other organizations sought to shield themselves from comparable lawsuits.

Prior to this case, the hospital contended that the attending physician was an autonomous contractor, exempt from oversight. Darling amended this tactic and set the stage for a consistent systematic evaluation of all physicians who asked to practice in the inpatient venue.

As such, the verification and evaluation of a physician’s credentials became the standard before inpatient privileges would be accorded.

Again, moving forward, it was in the 1990’s that national organizations devoted to the credentialing of medical providers came into being. The most well-known of these is NCQA, or the National Committee for Quality Assurance. This organization sets a range of standards that perform as a guide for how to credential medical providers, including the use of primary source verification which is the process of requesting and receiving verification of the provider’s stated credentials from the college or other entity that issued the diploma or certificate. This includes board certification, education, training, malpractice claims and other factors that can have a bearing on patient care.

While credentialing has obviously changed over the years, the heart of the concept is identical– ensuring doctors practicing in a given state or city have obtained the required training and possess the know-how to safely and capably practice medicine.

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