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In the medical field, there are many terms thrown around that can confuse even the most seasoned doctors and patients alike. It’s important for anyone in healthcare to understand the jargon. Take pyrexia for example, it’s just a fancy word for fever.
Now, when it comes to credentialing, enrollment, and privileging, those can seem like real tongue-twisters. But we can break it down nice and easy.
The differences between credentialing, enrollment, and privileging are complex ideas, but I’ll explain them simply.
Credentialing is the process of verifying a healthcare provider’s qualifications like their license, education, and training. It’s how hospitals make sure the doctors on staff are properly certified to practice medicine.
Privileging, on the other hand, authorizes specific healthcare providers to perform certain medical procedures based on their experience and expertise. For instance, a hospital may privilege only the most senior surgeons to conduct complex operations.
Enrollment refers to a healthcare provider joining a health insurance network so they can bill and get paid for treating patients with that insurance. Whether it’s with private insurance companies or government programs like Medicare and Medicaid, enrollment allows doctors to provide care to more people.
Now that you understand credentialing, enrollment, and privileging, you can see how they differ. Credentialing focuses on a practitioner’s general qualifications, privileging on their specific abilities, and enrollment on allowing them to serve patients with certain health coverage. Together, these three processes help ensure patients receive proper care from qualified and authorized healthcare providers.
What is Credentialing?
Basically, credentialing in healthcare is a process that guarantees patients are being treated by professionals who have qualification, certification, required education, and experience which is necessary for providing care at a healthcare facility. This ensures patients receive the highest level of care from healthcare providers or practitioners.
Usually, as discussed above, the process of medical credentialing involves verification of license, documentation, and clinical practice history of healthcare providers to ensure that they meet the set standards and regulations of delivering treatment at a particular healthcare facility.
The 5-Step Credentialing Process
Before delivering treatment to any patient, healthcare providers undergo a complete process referred to as the credentialing process. It is vital for maintaining quality and integrity of healthcare services. The step-by-step process of credentialing is mentioned below.
Step #1 – Application
The first step in the credentialing process is submitting an application. Providers apply to the organization i.e. NPDB (National Practitioner Data Bank), ABMS (The American Board of Medical Specialties), and AANP (American Association of Nurse Practitioners). In addition, OIG (The Office of Inspector General) and SAM (System for Award Management) also assist verify healthcare providers.
Step #2 – Verification
The organizations thoroughly inspect their credentials by contacting various related departments i.e. providers’ educational institutions, licensing boards, work stations where they had worked previously for assessing their experience, and other relevant departments.
Step #3 – Review
After verification, the concerned organization reviews the data received from the relevant departments and matches it with the data provided by the practitioners. So, if they meet the required standards of education, skills, training, and experience necessary for safe and effective treatment, the organization goes for the next step.
Step #4 – Approval
This is the first step towards practicing at a facility when the organization approves the providers’ applications after reviewing them.
Step #5 – Monitoring
The process of credentialing does not stop here. The organizations continuously monitor the providers’ credentials to remain in compliance with current year standards. If at any time in the year, they feel that the providers do not match the updated standards, they can restrict the providers from delivering treatment services.
In this case, providers should apply for re-credentialing by providing necessary documentation. Sometimes, hospital privileges and credentialing also end due to the working time mentioned in the contract with facilities i.e. three months or two years.
Who Verifies Credentials?
Do you know to whom the credentials are submitted and who verifies them?
There are various agencies and organizations that verify credentials after checking primary sources. Some of them are:
- National Practitioner Data Bank (NPDB)
- The American Board of Medical Specialties (ABMS)
- American Association of Nurse Practitioners (AANP)
- The Office of Inspector General (OIG)
- System for Award Management (SAM)
- State License Verification Websites
What is a Credentialing Checklist?
A credentialing checklist incorporates documents and data which are required for the credentialing process in healthcare.
Check list of credentialing documents needed for new physicians:
- Personal information
- Driver’s license
- Social Security card
- Medicaid number
- Medicare number
- Federal Tax ID number
- Permanent Resident Card, Green Card or visa status for non-US citizens
- Copy of all current active state license wallet
- Copy of current Federal DEA and current State Controlled Substance Registrations or certificate(s)
- Copy of medical school diploma and training certificate(s), internship, residency and fellowship certificates
- Copy of current Board Certificate, including the name of issuing board and dates of board certification/recertification
- Work history including all practice locations and employment affiliations
- Professional and personal references
- Malpractice claims history with details
- 10-year insurance claims report
- DEA certificate
- Personal immunization records
- CAQH enrollment
- OIG/SAM Exclusion Check
These were the credentialing requirements for physicians. Before filing an application, the physicians must arrange these documents.
Why is Credentialing Needed?
Credentialing plays a vital role in standardizing healthcare services. There are various benefits of credentialing. After reading about them you can get a clear idea why credentialing is needed. The benefits are:
Patient Safety
As a result of the credentialing process in healthcare, only professional and qualified practitioners are allowed to provide care which can reduce medical errors.
Credibility
Credentialing strengthens the reputation and trustworthiness of qualified healthcare providers.
Compliance Assurance
After credentialing, healthcare facilities adhere to the regulatory required and standards set by the organizations.
Trust Building
Patients have more trust and confidence in skills and expertise of credentialed healthcare providers.
Revenue Increase
Credentialed practitioners can receive more patients due to various referrals which can lead to revenue increase.
What is Privileging in Healthcare?
Privileging in healthcare means allowing healthcare professionals to perform specific medical procedures or services within a particular facility. Their privileges are based on their credentials and experience.
In simple words you can say that due to the privileging right, physicians provide their services at the most appropriate healthcare facility which reduces the overall risk of healthcare organizations.
Usually, privileging is the second step after the credentialing process. Upon completing the credentialing, healthcare professionals are granted privileges.
What is Clinical or Hospital Privileging?
Clinical or hospital privileging is when a healthcare practitioner is allowed to perform a specific care procedure of a patient at a particular healthcare facility. There are four types of hospital privileges.
Types of Hospital Privileges
Types of clinical or hospital privileges are:
Admitting Privileges
Admitting Privileges are the rights of a physician granted by the hospital to admit patients for treatment to that particular hospital or healthcare facility.
Courtesy privileges
Courtesy privileges authorize physicians for occasional treatment or admission to a hospital.
Surgical privileges
Surgical privileges allow physicians to perform outpatient or operating room surgeries.
What is the process of privileging?
The process of privileging involves these simple steps:
- Defining needed privileges based on the provider’s experience
- Provider application for specific privileges i.e. admitting, courtesy, and surgical privileges
- Verification of credentials i.e. education, training, and licensure
- Peer review to evaluate clinical competence and expertise
- Approval for privileges by the healthcare facility
- Ongoing monitoring and evaluation of provider’s performance
What is Enrollment in Healthcare?
Enrollment is the process in which healthcare providers or practitioners apply for inclusion in an insurance providers’ network to receive reimbursement after providing care services to patients.
After credentialing, practitioners get privileges from providers to perform at a specific facility. After that they are asked to apply for enrollment and come in network with insurers. The process of enrollment is the last part of the chain i.e. credentialing, privileging, and enrollment.
The 3-Step Enrollment Process
The process usually takes several weeks to several months to complete depending how providers submit their applications. The enrolment process involves these various steps:
Step #1 – Application
Providers should submit an application for enrollment with insurers containing all the necessary details i.e. practice location, the services they provide, and their insurance coverage. Furthermore, the providers also need to provide essential documents i.e. license, malpractice insurance, and education and training credentialing.
Step #2 – Review
After the application, the insurance providers will thoroughly review the providers’ application and other supporting documents to decide whether they meet the required standards for participation in their network. They carefully review applications to enroll only those who can be the best for their reputation in the future.
Step #3 – Approval
If the insurance providers find that the providers are eligible for becoming their participant, they accept their application.
Information and Documents Required for Enrollment
You will need to have the following information and documents during the process of enrollment:
- Work and medical staffing history
- Any existing practice privileges
- Medical license information
- Proof of medical practice liability insurance
- Education information
- Graduate medical training
- Any information of federal or state sanctions
- Proof of DEA registration
- Information on any board certification
- Peer references
- CME information
- Clinical reports cards and performance reviews
Why Is Provider Enrollment Important?
The importance of provider enrollment cannot be denied. It brings several benefits. It allows healthcare providers to become eligible for getting reimbursed after they provide care services to patients who are in network with the same insurers with whom the providers are. This will increase the financial capability of the practice by providing treatment services to more patients.
Furthermore, healthcare enrollment also facilitates patients to access a wide range of practices for better treatment as there may be many in-network healthcare providers with insurance companies. Patients utilizing their coverage benefits can seek better treatment anywhere, but only when the practices are preferred providers.
Conclusion
| Feature | Credentialing | Privileging | Enrollment |
| Definition | Verifying healthcare providers’ qualifications and background. | Granting specific clinical practice rights within a facility. | Process for healthcare providers to join an insurance network. |
| Purpose | Ensure patient safety and quality care. | Define scope of practice within a facility. | Enable providers to receive payment for services from insurance. |
| Process | Application, verification, review, approval, monitoring. | Application, verification, peer review, approval, monitoring. | Application, review, approval. |
| Outcome | Qualified providers can practice at a facility. | Providers can perform specific procedures at a facility. | Providers can bill insurance for services rendered to patients. |
| Key Players | Healthcare facilities, credentialing bodies, providers. | Healthcare facilities, providers. | Healthcare providers, insurance companies. |
| Timeline | Ongoing process with periodic re-credentialing. | Ongoing process with periodic re-privileging. | Ongoing process with potential changes during open enrollment. |
FAQs
What are the four levels of credentialing procedures?
The four level of credentialing procedures are:
- Provisional: No experience required, but requires 40-hour NACP pre-approved training program
- Basic: Minimum 3900 hours of experience
- Intermediate: Minimum of 7,800 hours of experience
- Advanced: Minimum of 15,600 hours of experience
What are the mechanisms of credentialing?
Here you can know how the credentialing works. Mechanisms of the credentialing are:
- Submitting application
- Verification of primary source
- Peer references
- Review
- Decision
- Privileging (if verified)
- Monitoring
- Re- credentialing
What are three privileges that healthcare professionals have?
- Admitting privileges
- Courtesy privileges
- Surgical privileges
What is open enrollment?
Open enrollment is a specific time period usually in the fall in which participants are allowed to login, and adjust or cancel their enrollment plan. However, it happens once in a year limited to few weeks. If a participant could not perform such actions in that particular time frame, they have to wait for the whole year for the next open enrollment period to make changes.
What is a payer enrollment?
Payer enrollment is the same as provider enrollment i.e. the process of a provider joining a health insurance plan.
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