Credentialing and Privileging: Essential Processes for Physician Success

By Editor
Nov 3, 2015
3 min read

As a provider, you already know about the importance of credentialing and privileging, two critical aspects that ensure high-quality service and patient safety, but do you really know how each differs in its definition, purpose and application process?

The Physician Credentialing Process: Step One

Let’s face it, you worked hard to become a physician, so credentialing — the complex process of assessing and confirming the qualifications of the healthcare practitioner — is an important part of your ability to bring quality services to patients. The term simply refers to the verification and documentation process that confirms you, as a medical practitioner, have the specialized qualifications, background and “credentials” necessary for membership (or a position) in a specific healthcare organization.

The process includes the confirmation of professional and academic degrees, clinical training, licensures, residency or training certificates, continuing education credits and more, and is used to assess a candidate’s qualifications to determine whether state and/or federal boards have confirmed that the applicant meets the standards of practice and rules and regulations set forth for medical staff by each institution.

Typical Documentation Required for Credentialing Include:

Proof of Identification
Proof of Education, Training and Certification
Proof of Current DEA Licensure
Military Service
Work Experience
Proof of Current Medical Licensure
Board Certifications
Hospital Affiliations
Letters of Reference
Health Status
Malpractice Insurance and Claims History
Criminal Background Information
Sanctions Disclosures

Physician Credentialing & Privileging: A Complex and Timely Process

Credentialing can be a very complex and time-consuming process as there is no currently centralized process in place. This means you must create submissions to each entity, and must be aware of the necessity of thorough recordkeeping to ensure that all information is completed, documented and error free.

Physician Credentialing, Step Two: Applying for Privileges

When credentialing has been completed, it’s time to apply for privileges, the process whereby the applicant is granted the authorization to provide a specific service, procedure or treat a certain condition at a specified healthcare facility.

Privileging typically falls into three primary categories, including:

Admitting Privilege — Allows a doctor to admit a patient to the hospital
Courtesy Privilege — Allows physicians to occasionally treat or admit at the hospital
Surgical Privilege — Allows the physician to perform outpatient or operating room surgeries

This important step in the physician credentialing process ensures the healthcare facility that the applicant has the skills, experience and competencies necessary for the clinical services they plan to provide. When privileging is approved, it signifies that the practitioner is sanctioned to conduct specific services at that facility. For instance, a doctor in private practice may apply for hospital privileges where he/she seeks to perform surgeries, and may even choose to obtain privileges at more than one hospital to comply with requirements set forth by medical insurance providers.

In addition, hospitals and other medical facilities must do their part by answering to regulatory entities such as The Joint Commission on Accreditation of Healthcare Organizations to ensure that physicians are appropriately privileged at their facility.

Again, Record-keeping is a Must!

Similar to credentialing, the privileging process can be complex and detailed. A physician must demonstrate competency, education, residency, fellowships, insurance, licensure, practical experience and more — and be prepared to undergo in-depth interviews with a credentialing committee, a medical executive committee and a board of directors — all integral parts of the investigation process.

Physician Credentialing & Privileging: Key Takeaways

Credentialing and privileging are formal, documented procedures that require adherence to each institution’s, state’s and specialty’s specific rules and regulations for granting admission and clinical privileges. That said, they are an essential part of providing patients with the highest possible standards and levels of care.