Professional Credentialing Services have long been the quiet fighters of the healthcare industry in regards to healthcare. While there used to be only a handful of such services available in the beginning, today’s industry has evolved into a large, trillion-dollar industry, fueled primarily by high-quality standards and professionalism. However, few individuals know that professional credentialing services aren’t just about managing the professional’s credentials. They’re about making sure that everyone involved in the process – from the doctor all the way down to the patient – knows what they’re doing. And this leads to an even bigger problem: how to ensure that everyone gets what they’re paying for.
The first step in any professional credentialing services process is to verify the accreditation and legitimacy of the organization carrying out the review. Many organizations that oversee medical practice – such as the American Board of Medical Specialties (ABMS) and the American Health Security Association (AHSA) – are recognized and highly respected as reliable and credible sources for checking the validity and quality of medical education and training. These associations also frequently serve as gatekeepers for licensed professionals who wish to enter the field of healthcare. They can perform a check on the professional credentials of potential applicants.
Once the review is complete, the next step is to conduct in-house or field-based verification of the information submitted by the applicants. This includes verifying the type of certifications that each candidate possesses, checking for evidence of prior education and training, if any, assessing whether each claim is valid according to the current regulatory framework, and comparing the details of each set of credentials with those of the applicable State regulatory body. While the specifics will vary from healthcare organizations to healthcare organizations, some general rule rules are available for practice in both in-house and field-based credentialing systems. Some of these general rules include:
Healthcare professionals need to remember that a list of acceptable certifications should not be considered an end-all. It should instead be viewed as a starting point, and any deviation should be addressed to ensure that the desired outcome is achieved. To this end, many healthcare professional organizations require in-house or field-based verification of all credentialed information. For example, some organizations conduct enrollment audits to ensure that the list of accepted certifications is accurate, up-to-date, and includes recommended renewals.
After the in-house or field-based verification of each CPE, the list is sent for approval to approved Professional Credentialing Organizations (PCOs). All qualified healthcare professionals are required to apply for these licenses. Once approved, these organizations provide the application forms to eligible healthcare professionals. The application requires detailed information about the credentialing process. To expedite the credentialing process, organizations have implemented a data integrity system that verifies each piece of data before sending it to the entire membership. The data integrity process ensures that the credentialing information meets or exceeds the highest level of quality.
When not satisfied with the initial list of CPE’s, healthcare professionals may need to re-apply for their medical billing privileges. Professional credentialing companies perform a more in-depth review of each application to determine whether it meets all requirements. When approved, these applications are then sent to the approved Medical Credentialing Service (MCS) or Medical Terminology Organization (MTO) for review. For an application to move forward, it must pass the highest standard of quality. The review involves multiple agencies and quality control checks.
A certification credentialing process is important because it indicates to the organization and the public that a healthcare provider has met standards of quality and has been thoroughly verified. When a patient sees an organization’s certification credential, they have increased confidence and trust in that organization and the provider. Increased client satisfaction and better patient volume often result from a well verifying and accredited credentialing process.
There are two primary ways that credentialing experts perform their job. First, they perform discovery using onsite investigation and record checks of each application. Second, they perform enrollment either manually or automatically. Manual credentialing certification verification typically occurs before application approval. Automatic credentialing enrollment occurs when a provider submits a manual application, receives confirmation of acceptance or denial, and, if the application is denied, performs enrollment again using the same process.