Credentialing is a formal process that utilizes an established series of guidelines to ensure that patients receive the highest level of care from healthcare professionals who have undergone the most stringent scrutiny regarding their ability to practice medicine. Credentialing also assures the patient that he or she is being treated by providers whose qualifications, training, licensure, and ability to practice medicine are acceptable. Credentialing also ensures that all healthcare workers are held to the same standard. ,,
In the current era of medical practice, all healthcare institutions have the onus of ensuring patient safety and delivering an acceptable standard of care. While employing excellent medical staff is vital for success, the healthcare institution must have medical bylaws that define the required minimum credentialing and privileging requirements to validate the competency of healthcare providers. In the past, only hospitals used to perform credentialing, but today almost all healthcare facilities, ambulatory care centers, long-term care institutions, and even urgent care clinics perform credentialing.
Credentialing is a vital process for all healthcare institutions that must be performed to ensure that those healthcare workers who will be providing the clinical services are qualified to do so. There are ample cases reported in the literature about healthcare workers who worked in hospitals with bogus certificated and falsified experience.
Over the past 20 years, the credentialing process has become complex and onerous primarily due to the expansion of the provider scope of practice, accrediting bodies, and requirements of third-party payers like Medicare, Medicaid, and private insurers.
Credentialing is a vital process for healthcare institutions. In simple terms, credentialing is the process of assessing the academic qualifications and clinical practice history of a healthcare provider. Credentialing is not a novel concept and has been practiced for more than 1000 years, when physicians in Persia had to demonstrate their skills and training before they were allowed to practice their art.
The process of credentialing has become more refined and thorough over the past 50 years. Today there are several national agencies that are dedicated to maintaining the standards of credentialing for healthcare providers. The National Committee for Quality Assurance (NCQA) has established a set of standards that currently act as a guideline on how to credential health care providers,,. One of the key features of NCQA, as it pertains to credentialing, is to check with the primary source to verify any certificate, diploma, or degree. Simply asking the healthcare provider to submit an original diploma or degree is no longer sufficient for credentialing. Furthermore, the healthcare institution or licensing board must also check with the primary source regarding education and training. In addition, information should be obtained on any malpractice claims and several other factors that may have an impact on clinical practice.
The Process of Credentialing
Healthcare institutions should have staff bylaws that guide administrative processes that ensure that healthcare workers provide competent and safe care.
All healthcare workers should understand that practicing clinical medicine is a privilege and it goes hand-in-hand with first being credentialed. After the individual is credentialed, the next step is to address the privileges of practice, which depend on the evaluation of the provider’s clinical qualifications, training, and overall performance. For privileges and credentialing, the bylaws should address the following:
Who Requires Credentialing?
In general, any licensed, independent, healthcare professional who has been permitted by law and regulated by a licensing organization to provide services and care without supervision or direction within the scope of the individual’s license needs to be credentialed. While every state has unique laws regarding medical practice, simply having a license in a healthcare profession does not mean one can start doing anything they want. For example, an advanced nurse practitioner cannot independently start to prescribe medications, or a family physician cannot begin inserting central lines. Even independent nurse practitioners have to follow specific rules, and in certain states, they work under a physician. Simply being licensed does not mean the healthcare professional is at liberty to perform all types of clinical services. Every healthcare worker has a role to play, and once a license is obtained, they can only perform a function for which they are granted privileges. ,,,
Privileging is the process whereby a healthcare worker is authorized to perform a specific set of patient care services, based on an evaluation of the individual’s credentials and performance. A “privilege’ is defined as a benefit that is not available to all healthcare workers.
Agencies that Verify Credentials
Today there are several agencies and organizations that check the primary sources for verification of credentials (Anon, 2018; Epstein & Epstein, 2012). Some of these include the following:
National Practitioner Data Bank: The NPDB is a US government program that gathers data and provides it to authorized users. The type of data collected includes negative complaints, malpractice cases and awards, loss of privileges, loss of professional society membership, suspension of license, revocation of a license or expulsion from participation in Medicaid or Medicare programs. The NPDM was created by Congress with the primary goal of protecting the public and decreasing healthcare fraud and abuse. The NPDB is managed by the Bureau of Health Workforce and Health Resources and Services Administration.
Data from NPDM is only available to healthcare workers, hospitals, professional societies and licensing agencies or contractors who administer federal care programs. Individual healthcare providers can obtain access to their own record by paying a small fee. When applying for a license in many states, one has to submit the NPDB data.
The American Board of Medical Specialties (ABMS) was established in 1933 and is a non-profit organization that represents 24 broad disciplines of medicine. The board functions to maintain a rigorous process or evaluation of board certification of American physicians. ABMS certifies over 150 medical specialties. The board also collaborates with other professional medical agencies and organization to set standards for residents and accreditation of residency programs. The information on ABMS is available to the public.
American Association of Nurse Practitioners (AANP)/American Nurses Credentialing Center (ANCC) are 2 separate agencies that also verify if the nurse is board certified.
Sanctions and Exclusions
The Office of Inspector General (OIG) and the System for Award Management (SAM) are two agencies that also help verify if healthcare providers have any restrictions/sanctions against their medical license that may limit their ability to practice clinical medicine.
State License Verification Websites
Each state has a medical board that operates a license verification program. These are further separated into nursing, dental, podiatrists, doctor of osteopathy, and physicians/physician assistant. 
The Legal Issues
All healthcare institutions that develop written policies that govern credentialing and privileges must consult with legal counsel to ensure that the policies abide by state laws, and professional organization and federal requirements. In addition, the institution must ensure that credentialing is a fair, unbiased process and there is in place a method for review of any grievances.
Identification of the Applicant
With every application, the healthcare worker must supply some type of government-issued identification and a photograph. In fact, many hospitals now require that the photograph is stamped and notarized. When the hospitals request references, they should send the applicant's photo identification together with the request to ensure that the applicant has not been misusing someone else’s identification.
Background check: Today most healthcare institutions perform a background check on all applicants. A background check may reveal any criminal or domestic violence at both the state and federal levels. Some states recommend that hospitals also request that applicants provide a copy of the police report.
Processing of the Application
Once the applicant’s application is received and approved the healthcare provider can request for privileges.
Credentialing for Special Circumstances
Providers of Telemedicine
As delivery of healthcare evolves, some physicians are now allowed to practice telemedicine, but within reason. Sometimes radiologists support emergency rooms by reviewing CT scans or questionable x-rays done in the middle of the night. In fact, the Centers for Medicare and Medicaid Services is now permitting healthcare institutions whose patients are receiving telemedicine services to grant privileges and credentialing to some physicians providing ambulatory surgery care and teleradiology. It should be understood that most licensing boards do not permit the prescription of controlled substances or examining of patients via telemedicine. The hospitals must have a specific standard with regards to the practice of telemedicine because it has the potential for abuse. Many insurers and state licensing boards only agree to the practice of telemedicine with oversight to ensure that patients are receiving appropriate care.
Red Flags in Credentialing
Credentialing often reveals many things about a healthcare professional's past. While some of them may be benign events, a significant number of healthcare professionals who apply for credentialing come with questionable papers and inadequate clinical experience. Some of the warning signs include:
Structure of Credentialing
The Application Process
Most healthcare institutions use a 2-step application process. The initial pre-application is to ensure that the applicant has met with the basic qualifications for hire at the institution.
The pre-application is a screening process and saves considerable time and resources in identifying individuals who do not even have the minimum requirements for the job. The pre-application usually assesses the following:
Together with the CV, the pre-application is reviewed, and if there are any outstanding issues, the applicant is either asked to submit more material or is denied the formal application.
If the healthcare worker is found to have questionable credentials, then he or she must be told in writing that the appropriate board, agencies, or organizations will be contacted for further investigations
The Formal Application
Once the pre-application has met the minimum requirements for credentialing, then the individual is sent a formal application. During the final application, the following are usually evaluated:
All healthcare institutions are responsible for ensuring that their medical staff is competent through a bona fide credentialing process. Today the credentialing process is not only tied to the demonstration of proper education and training but also maintains accreditation standards reimbursement requirements, and satisfies state and federal laws.
While the credentialing process may vary among healthcare institutions, it is vital that the primary source is always checked to make sure that the papers submitted are not fraudulent. A proper structured credentialing process can prevent admission of rogue healthcare workers with dubious qualifications, which also helps ensure a better quality of patient care. Once credentialed, all healthcare workers should be continuously audited for their performance. In today's era of quality care, there is little room for error.
Granting of Privileges
Once the credentialing process is over, the committee must have a process of granting privileges. This may include allowing the healthcare professional to work with limited privileges, full privileges or be denied privileges.
It is important to grant privileges specific to the healthcare worker’s training and experience. For example, a family doctor who joins the hospital should not be allowed to perform repair of lacerations or insert central lines.The hospital always has to take into account the potential risks when generating privileges for newly credentialed healthcare workers.
The granting of privileges should be regularly updated. Plus the privilege information should be available to other departments. For example, a general surgeon may call the operating room in the middle of the night wanting to perform an abdominal aortic aneurysm repair, a procedure usually done by the vascular surgeon and the nurse may want to know if he or she has been granted privileges for doing this surgery. The emergency room may call to find out if a physician has admitting privileges.
No matter what decision is made on granting or denying privileges to a healthcare worker, the information should be relayed in writing within a specific time frame. Further, this information should also be made available to all appropriate external or internal entities within the hospital.
When privileges are denied, the healthcare institution should have a system for appeal for healthcare workers.
Professional Practice Monitoring and Evaluation
Once a healthcare worker has been credentialed, and he or she is granted privileges to practice medicine, most hospitals have developed a program of monitoring or a proctoring period. This is vital for surgeons. For example, a newly trained vascular surgeon must be proctored for 5 to 15 cases to determine not only his or her hand skills but also to assess his or her clinical competence and criteria for doing the surgery. To ensure that the proctoring is unbiased the committee needs to develop guidelines which include the following:
Performance Monitoring Methods