DCMS: Articles: Credentialing

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Articles and Publications

Credentialing:
The Pennsylvania Medical Society Keeping You Informed

The Pennsylvania Medical Society is committed to providing our resident and fellow members with important information to help you grow as professionals and provide excellent patient care. We are dedicated to protecting and strengthening the physician-patient relationship, something that is of great importance to physicians throughout their careers. We are pleased to present this brief document, which we hope will help to facilitate a smooth transition from training to active practice.

The Credentialing Process
Because the credentialing process can take up to several months, physicians should begin filling out parts of the application and collecting necessary documentation as early as possible. You can even begin the process before completing residency.

The State Society offers the following tips and resources to help you prepare and to ease the credentialing process:

Things You Need to Know About Credentialing
The Credentialing Process
National Committee for Quality Assurance (NCQA) Requirements

For more information, see:

Credentialing Checklist
Pennsylvania Standard Application (The standard application can be found in PDF format on the Web site. Go to www.pamedsoc.org and click on Member Resource Center/Practice Management/Credentialing Process.)

Things You Need to Know About Credentialing

Managed care plans will not allow you to see their members until you are credentialed.

The impact of a non-credentialed physician on a practice’s revenues stream can be enormous. Unlike Medicare/Medicaid, most managed care plans will not allow you to bill for services retroactively.

The Credentialing Process

Step I

The physician applicant submits credentialing forms to provider organizations. Including information regarding the physician’s:

Education, training, work experience
Present health status
Current and previous healthcare organization affiliations
Malpractice history and information related to disciplinary actions if applicable.

Step II

The healthcare organization collects and verifies information by querying several national information banks. They gather and confirm data regarding the physician’s:

Highest level of training
Current licensure
Malpractice Insurance
Claims History

Accreditation organizations, such as the National Committee for Quality Assurance (NCQA) and the Medical Quality Commission have specific rules regarding the process used for verification of physician information.

Step III

The healthcare organization makes a decision based on the outcome of the data compiled during the routing of the credentials application through the verification process (which may take from 30 days to more than six months). When physicians are contracted with a large number of health plans and medical groups, the duplicative activities are enormous.

National Committee for Quality Assurance (NCQA) Requirements

The NCQA requires managed care organizations to verify each of the following pieces of information before credentialing a physician:

A current, valid license to practice
The status of clinical privileges at the hospital designated by the physician as the primary admitting facility, as applicable
A valid Drug Enforcement Administration or Controlled Dangerous Substance certificate, as applicable
The education and training of the physician
The applicant’s board certification, if the physician says on the application that he or she is board certified
The applicant’s work history
Malpractice coverage that is current and adequate to satisfy the MCO’s policy
The applicant’s history of professional liability claims that resulted in settlements or judgments paid by or on behalf of the physician.

Go to the Credentialing Checklist for a handy list of all the items you’ll need to obtain hospital privileges.