NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.
Roshan Patel ; Sandeep Sharma .
Last Update: October 24, 2022 .
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 patients that they are 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.[1][2][3]
Credentialing and Privileges in Healthcare
In the current era of medical practice, all healthcare institutions ensure patient safety and deliver 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. Only hospitals used to perform credentialing in the past, 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. It must be performed to ensure that the healthcare workers who provide the clinical services are qualified to do so. The literature reports ample cases of healthcare workers who worked in hospitals with bogus certificates 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.
What is New in Credentialing?
Credentialing is a vital process for healthcare institutions. In simple terms, it is the process of assessing a healthcare provider's academic qualifications and clinical practice history. Credentialing is not a novel concept; it 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 credentialing process has become more refined and thorough over the past 50 years. Today, several national agencies are dedicated to maintaining the credentialing standards of healthcare providers. The National Committee for Quality Assurance (NCQA) has established standards that serve as guidelines for credentialing healthcare providers.[1][2][3] 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. Information on malpractice claims and other factors that may impact clinical practice should also be obtained.
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:
The pre-application process to screen if a healthcare professional satisfies the basic criteria for working in the hospital
Establish grounds for denying applications after the pre-application process. Establish a process where the rejected healthcare worker can re-apply after the initial denial. Have a process for rapid credentialing for locums, emergency staff, and short-term employment.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.
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.
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.
Establish a code of conduct rules for a healthcare worker who gets credentialed and the penalties for disregard.
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
