Credentialing is the process of getting a physician approved by hospitals to obtain privileges and approved by health plans to become a participating “in network provider”.
Hospital privileges
Hospitals grant privileges to physicians and other health care providers to use their facilities for patient care. Obtaining privileges should be the first step in credentialing, hospital privileges are essential for health plan credentialing. Since health plans maintain networks of a variety of physicians and hospitals, it is preferred physicians have admitting privileges at a participating hospital, if not it is required that the physician have a designated alternate that is participating on the plan that has agreed to admit patients on the physicians behalf or have a Hospitalist group at an in network facility.
Hospital privileges are specific to a physician’s specialty practice expertise. Before granting privileges, hospitals will complete an extensive verification for a physician’s credentials according to JCAHO standards. This process can take anywhere from two to six months sending on how quickly they receive back the verifications, in certain circumstances it may be possible to obtain temporary privileges. Once all information is received, the hospital’s credentials committee will review the information and verify the file is complete. The completed file goes to the hospital’s medical executive committee for approval and then presented to the board of directors for final approval.
Becoming a participating provider
Health plans create networks of participating physicians of all specialties, hospitals and labs etc., that have agreed to provide services to their members. The health plans require the physician who wish to become participating providers to complete their credentialing process. Majority of health plans will require the physician’s credentials to have been verified and the health plan’s credentialing committee approves before they will forward a contract to the physician for review/signature. Other plans will send a contract for review/signature then once the health plans have received the signed agreement they will at that time start the credentialing process. The entire process from start to finish can take anywhere from 30-180 days or longer if negotiating the contract applies.
Once the physician has become a participating provider it is so very important that a physician’s demographic information as in office location(s), Tax ID#, NPI# and specialty is verified that it is loaded correctly in their data base. If it is not loaded correctly many issues will occur that can be costly to the practice.