Definition/Introduction

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 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 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 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, 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 several national agencies 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.[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. The information should also be obtained on any malpractice claims and several other factors that may have an impact on clinical practice.

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 the evaluation of 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. Have steps in place to limit the practice of medicine for those healthcare workers who do not follow guidelines or the standard of care is not satisfactory
6. How to grant temporary privileges: Sometimes, 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 earthquake, 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 surgeons in cardiac surgery to ensure that they know what they are doing.

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 healthcare profession license does not mean one can provide any medical service they want. 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 in certain states, they work under a physician. Simply being licensed does not mean healthcare professionals are 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.[4][5][6][7]

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 data collected includes negative complaints, malpractice cases, 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 to protect the public and decrease 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 records 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 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 (AANP)/American Nurses Credentialing Center (ANCC) are two 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 assistants.[8]

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. The institution must also ensure that credentialing is a fair, unbiased process, and there is 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 privileges.

Credentialing for Special Circumstances

Providers of Telemedicine

As healthcare delivery 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 are 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 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 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:

• 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, the healthcare institution should promptly perform the initial credentialing so that healthcare workers are not left in limbo for months. The governing board should do the final approval of 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, each time changes are made in the credentialing process, legal counsel should first review them. 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 be getting old and prone to mistakes, and thus privileges for these surgeons should be limited to only 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 review and approval of applicants. The credentialing process and any decision should be documented and finally approved by the governing committee.
• All employers have to comply with the Americans with Disabilities Act. The 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 has met the basic qualifications for hire at the institution.

The 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

Together with the CV, the pre-application is reviewed. If there are any outstanding issues, the applicant must either 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 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 sent back 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 health status and vaccination. Most hospitals now mandate that physicians be vaccinated against hepatitis B. Some hospitals even require an annual influenza vaccine.
• The healthcare worker must submit to a mental and/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 revocation of the application.

Clinical Significance

All healthcare institutions are responsible for ensuring that their medical staff is competent through a bona fide credentialing process. Today, the credentialing process is tied to the demonstration of proper education and training and maintains accreditation standards reimbursement requirements and satisfies 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 proper 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 privileges, full privileges, or be denied privileges.[10]

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 a repair of lacerations or insert central lines. The hospital always has to consider the potential risks when generating privileges for newly credentialed healthcare workers.

The granting of privileges should be regularly updated. Plus, 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 doing this surgery. The emergency room may call to find out if a physician has admitting privileges.

No matter what decision is made 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 appeal 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 their management of a patient in the clinic.
• In some cases, only a retrospective chart review of the patient medical records may be possible. This should be done randomly on all healthcare workers who look after patients to ensure that they are compliant with the format of writing medical notes, dating each entry, checking the laboratory parameters, and following up on any abnormal results.

External Review

• Today many hospitals are turning to external reviews of their healthcare workers in selected cases. This allows for unbiased evaluations. For example, when there is a perceived conflict of interest or need for more objectively about disciplinary action, a second opinion is necessary. For example, a newly recruited cardiac surgeon would like to perform a relatively new procedure that has not been accepted in mainstream cardiac surgery, but the senior cardiac surgeon feels that the procedure has a high risk, and the traditional method of doing surgery is safer. To prevent animosity and chaos in the department, sometimes in such cases, a second opinion from another expert may be required. 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 colleague 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 an effort of an interprofessional team. Typically each hospital has a credentialing specialist who works for medical staff. The physician submits the application and supporting documents to the credential specialist. The hospital conducts primary source verification. For primary source verification, Hospital gathers information directly from original sources like ECFMG, medical school, residency training program, state medical board, etc.  Credentialing specialist brings reports to the hospital credentialing committee. Credentialing Committee is usually made up of members elected from different departments to serve on the committee. When a physician has a malpractice claim or any other negative facts in the application, credential committee members discuss the application on individual bases and make recommendations based on hospital needs and physician qualification. If the application is clear from all sources, then the credentialing committee approves the application. Typically 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 is usually made up of the chiefs of different sections, legal department, risk management, and administrative personnel. The hospital board of directors reviews the application only after approval from the medical executive committee. The hospital board of directors gives final approval to grant privileges so the physician can work in the hospital.