Credentialing

Issues of Concern

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 evaluating the provider’s clinical qualifications, training, and overall performance. For privileges and credentialing, the bylaws should address the following:

1. The pre-application process to screen if a healthcare professional satisfies the basic criteria for working in the hospital
2. Establish grounds for denying applications after the pre-application process.
3. Establish a process where the rejected healthcare worker can re-apply after the initial denial.
4. Have a process for rapid credentialing for locums, emergency staff, and short-term employment.
5. Steps should be taken to limit the practice of medicine for healthcare workers who do not follow guidelines or the standard of care is unsatisfactory.
6. How to grant temporary privileges: An outside medical or surgical specialist may be asked to offer advice or perform a life-saving procedure. In such scenarios, the bylaws should be able to accommodate them.
7. Granting emergency privileges to healthcare professionals in times of disasters (for example, during floods or earthquakes, there may be an urgent need to have the staff to look after the patients.
8. Establish a code of conduct rules for a healthcare worker who gets credentialed and the penalties for disregard.
9. Granting privileges with shadowing: Many times, physicians and surgeons from outside the United States may have different training. Before granting full privileges, these healthcare workers may need shadowing or proctoring for a few weeks or months. For example, many hospitals have a process of proctoring cardiac surgery surgeons to ensure they know what they are doing.

Who Requires Credentialing?

In general, any licensed, independent healthcare professional 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 must be credentialed. While every state has unique laws regarding medical practice, simply having a healthcare professional license does not mean one can provide any medical service one wants. For example, an advanced nurse practitioner cannot independently start prescribing medications, or a family physician cannot begin inserting central lines. Even independent nurse practitioners have to follow specific rules, and they work under a physician in certain states. Simply being licensed does not mean healthcare professionals can perform all 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.[4][5][6][7]

Privileging occurs when 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 a benefit not available to all healthcare workers.

Agencies that Verify Credentials

Today, several agencies and organizations check primary sources to verify credentials, including the following:

National Practitioner Data Bank

The National Practitioner Data Bank (NPDB) is a US government program that gathers and provides data to authorized users. The data collected includes negative complaints, malpractice cases, awards, loss of privileges, professional society membership, suspension of license, revocation, or expulsion from participation in Medicaid or Medicare programs. Congress created the NPDM to protect the public and decrease healthcare fraud and abuse. The Bureau of Health Workforce and Health Resources and Services Administration manages the NPDB.

Data from NPDM are only available to healthcare workers, hospitals, professional societies, and licensing agencies or contractors who administer federal care programs. Individual healthcare providers can access their records by paying a small fee. When applying for a license in many states, one has to submit the NPDB data.

American Board of Medical Specialties 

The American Board of Medical Specialties (ABMS) was established in 1933 and is a nonprofit organization representing 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 organizations to set standards for residents and accreditation of residency programs. The information on ABMS is available to the public.

American Association of Nurse Practitioners and American Nurses Credentialing Center 

The American Association of Nurse Practitioners (AANP) and the American Nurses Credentialing Center (ANCC) are separate agencies that verify whether a nurse is board-certified.

Sanctions and Exclusions

The Office of Inspector General (OIG) and the System for Award Management (SAM) are 2 agencies that also help verify if healthcare providers have any restrictions or 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 and physician assistants.[8]

The Legal Issues

All healthcare institutions that develop written policies governing credentialing and privileges must consult with legal counsel to ensure that the policies abide by state laws, professional organizations, and federal requirements. The institution must also ensure that credentialing is a fair, unbiased process and that there is a method for reviewing any grievances.

Identification of the Applicant

The healthcare worker must supply government-issued identification and a photograph with every application. Many hospitals now require that the photograph be 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.

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

The healthcare provider can request privileges once the applicant’s application is received and approved.

Credentialing for Special Circumstances

Some physicians can now practice telemedicine as healthcare delivery evolves but within reason. Sometimes, radiologists support emergency rooms by reviewing computed tomography (CT) scans or questionable X-rays in the middle of the night. The Centers for Medicare and Medicaid Services now permit healthcare institutions whose patients receive 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 patients via telemedicine. The hospitals must have a specific standard regarding 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 may be benign events, many healthcare professionals who apply for credentialing come with questionable papers and inadequate clinical experience. Some of the warning signs include:

• The reluctance of the applicant to provide permission to contact the previous employer or healthcare institution
• The reluctance of the application to provide specific references or perhaps the references are too vague
• Sudden relinquishment of licensure or medical staff membership
• Sudden loss of privileges in a hospital
• Marked gaps in clinical practice
• Short tenure at multiple hospitals
• An unusually high number of professional liability actions with the final judgment against the practitioner[9]
• History reveals substance abuse, domestic violence, or unprofessional conduct.
• History of being investigated by the state board of licensure or other healthcare organizations
• Major gaps in insurance coverage
• Evidence of poor program evaluations more than once

Structure of Credentialing

• No healthcare worker should be permitted to work before completing the credentialing process. On the other hand, healthcare institutions should promptly perform initial credentialing so that healthcare workers are not left in limbo for months. The governing board should approve the final credentialing.
• External organization: Today, many agencies can verify credentials, and some healthcare institutions may work with these credential verification organizations to expedite the process, especially if the healthcare worker is from outside the United States or there is an immediate need for staff.
• Healthcare institutions should regularly review the credentialing process so that any new state or federal recommendations are updated. Furthermore, when changes are made in the credentialing process, legal counsel should review them first. The governing body usually does the final approval.
• There must be administrative internal remedies for questionable candidates whose credentials are borderline.
• Once a provider has been credentialed, the individual’s privileges should be reviewed every 2 years. This is very important because the provider may have learned new skills they may want to use. For example, a provider may have taken a course in bariatric surgery and may want to establish a program in the hospital. On the other hand, some providers may get old and prone to mistakes; thus, these surgeons' privileges should be limited to certain procedures. Other providers may have developed an ailment like seizures or Parkinson's disease, which may mean that they cannot work safely in the operating room, and thus, privileges have to be curtailed.
• The hospital should have bylaws that help establish a process for reviewing and approving applicants. The credentialing process and any decision should be documented and finally approved by the governing committee.
• All employers must comply with the Americans with Disabilities Act. An applicant cannot be discriminated against or denied credentialing just because of a disability.

The Application Process

Most healthcare institutions use a 2-step application process. The initial pre-application ensures that the applicant meets the basic qualifications for hire.

Pre-application

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:

• Having an unrestricted license
• Any disciplinary actions or sanctions by insurers, hospitals, licensing boards, or professional organizations
• Presence of any criminal history
• Is the individual board-certified
• General health status

The pre-application is reviewed together with the CV. If there are any outstanding issues, the applicant must submit more material or be denied the formal application.

Suppose the healthcare worker is found to have questionable credentials. In that case, he or she must be told in writing that the appropriate board, agencies, or organizations will be contacted for further investigations.

Formal application

Once the pre-application meets the minimum requirements for credentialing, the individual is sent a formal application. During the final application, the following are usually evaluated:

• The applicant should agree to provide continuous care to patients at an acceptable standard of care.
• The applicant should acknowledge receipt of the hospital bylaws, regulations, rules, and the Code of Conduct. A copy of the bylaws should be signed, dated, and returned to the credentialing committee.
• Always have in writing that all credentialed healthcare workers will have access to patient medical records, but the medical records will be randomly audited to assess quality and competence.
• The healthcare worker should provide information about the patient's health status and vaccination. Most hospitals now mandate that physicians be vaccinated against hepatitis B, and some hospitals even require an annual influenza vaccine.
• The healthcare worker must submit to a mental or physical exam as required by the institution if there is a need. Failure to agree may result in termination or suspension of privileges without a right to a hearing.
• If the healthcare wants additional privileges, he or she should submit the request in writing.
• The applicant must sign and agree that all the evidence, information, and diplomas are valid and complete. Any misstatements or omissions may be grounds for immediate termination of privileges or application revocation.

Clinical Significance

All healthcare institutions are responsible for ensuring their medical staff is competent through a bona fide credentialing process. Today, the credentialing process is tied to demonstrating proper education and training, maintaining accreditation standards and reimbursement requirements, and satisfying state and federal laws.

While the credentialing process may vary among healthcare institutions, the primary source must always be checked to ensure that the papers submitted are not fraudulent. A properly structured credentialing process can prevent the 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.

Nursing, Allied Health, and Interprofessional Team Interventions

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, full, or denied privileges.[10]

Granting privileges specific to the healthcare worker’s training and experience is important. For example, a family doctor who joins the hospital should not be allowed to perform a repair of lacerations or insert central lines. The hospital must always consider the potential risks when generating privileges for newly credentialed healthcare workers.

The granting of privileges should be regularly updated, and the privileged 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 this surgery. The emergency room may call to determine if a physician has admitting privileges.

No matter the decision to grant or deny 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 appeals for healthcare workers.

Professional Practice Monitoring and Evaluation

Once a healthcare worker has been credentialed and is granted privileges to practice medicine, most hospitals have developed a monitoring program or a proctoring period. This is vital for surgeons.[11] For example, a newly trained vascular surgeon must be proctored for 5 to 15 cases to determine his or her hand skills and 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:

• Identify what specific criteria will be proctored. Clinical skills, surgical technique
• How will proctoring be done, and for what period?
• Who will be in charge of the actual proctoring?
• Will the physician be given a warning of proctoring?
• In what circumstance would an external proctor be brought in?
• What if the healthcare professional fails proctoring? Will the privileges be rescinded? Will they only be able to assist or work under supervision, and for how long?

Performance Monitoring Methods

• Once a healthcare worker has been credentialed and his or her privileges are approved, the hospital must have established performance monitoring methods. This may be done with proctoring.
• The healthcare provider may be provided with potential cases and suggest treatment plans. This may be done verbally or by text.
• Another way to proctor is for a senior staff member to observe the healthcare provider perform a procedure or review the management of a patient in the clinic.
• Sometimes, only a retrospective chart review of the patient's medical records may be possible. This should be done randomly on all healthcare workers who look after patients to ensure that they comply with the format of writing medical notes, date each entry, check the laboratory parameters, and follow up on any abnormal results.

External Review

• Many hospitals are turning to external reviews of their healthcare workers in selected cases. This allows for unbiased evaluations. For example, a second opinion is necessary when there is a perceived conflict of interest or a need for more objective disciplinary action. For example, a newly recruited cardiac surgeon would like to perform a relatively new procedure that has not been accepted in mainstream cardiac surgery. Still, the senior cardiac surgeon feels that the procedure is highly risky and the traditional surgery method is safer. Sometimes, a second opinion from another expert may be required to prevent animosity and chaos in the department. Furthermore, sometimes, a second opinion may also help determine the healthcare worker’s state of mind. A physician's behavior may be erratic, and he may not be performing up to par, but all his colleagues feel that something is wrong with him. The physician is then sent for an internal mental evaluation, which he later claims was biased. In such cases, an independent medical examination may provide benefits as it helps to get an unbiased opinion.[12]
• External reviews are also useful when the number of healthcare workers is small and no appropriate peer reviewer is available.
• It is also important to get an external review when the healthcare worker has appealed a decision or if litigation is likely.
• An external review is also helpful when the staff is experienced and relatively new.

Nursing, Allied Health, and Interprofessional Team Monitoring

Credentialing requires the effort of an interprofessional team. Typically, each hospital has a credentialing specialist who works for medical staff. The physician applies supporting documents to the credential specialist. The hospital conducts primary source verification. For primary source verification, the Hospital gathers information directly from sources like ECFMG, medical schools, residency training programs, state medical boards, etc.  The credentialing specialist brings reports to the hospital credentialing committee. The Credentialing Committee is usually composed of members elected from different departments to serve on the committee. When a physician has a malpractice claim or other negative facts, credential committee members discuss the application individually and make recommendations based on hospital needs and physician qualifications. If the application is clear from all sources, the credentialing committee approves the application. Typically, the credentialling committee meets every 1 to 3 months. The application is then forwarded to the medical executive committee meeting for review. The medical executive committee usually comprises the chiefs of different sections, the legal department, risk management, and administrative personnel. The hospital board of directors reviews the application only after the medical executive committee approves. The hospital board of directors gives final approval to grant privileges so the physician can work in the hospital.