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What You Need to Understand About Physician Credentialing

The managed care insurance companies, the physician offices, the hospitals and the laboratories all credential the physicians. You must know that credentialing is one act of collecting information regarding the doctor or the medical provider to ascertain their qualifications in practicing medicine according to their specialty.

There are a lot of agencies that oversee the credentialing processes. There is a leading agency which monitors the credential and also the qualification standards in healthcare. The medical providers should go through the credentialing process before they are being hired by the medical facilities as well as the insurance companies. Physician credentialing or medical credentialing is going to verify the training, licensure, quality, education and also the general ethical standing of the provider in a particular medical community.

The credential process of the doctor would start with the medical provider submitting information to such credentialing agency for evaluation. The areas of focus are malpractice claims, board certification, education, licenses, resume, background check, resume as well as detailed work history, personal preferences, malpractice insurance, privileges as well as other information.

The information gathered are going to be reviewed by a physician peer-review committee. The committees would actually make recommendations to the professional as well as the standing of the provider in the community. The physician’s ethical behaviors would also be evaluated by the committees.

The insurance companies including the government-sponsored payers, will look for the physician’s medical credentials before accepting the professional into a group of participating providers. The Medicare and also the Medicaid won’t allow the physicians to have not undergone their credential procedures to bill for their services. The managed care organizations do have a firm physician credentialing process before the provider would be listed as participated with the insurance company. A lot of private physician practices would credential the doctors to make sure of quality care delivery.

Know that provider credential is one way to assure the consumers that the medical providers have been reviewed by the peers. This would also provide such higher level of trust and ensure that the provider is licensed and also certified and hasn’t had their licenses or their privileges revoked by the other state. But, such cannot determine the quality of the care offered by the provider. Many of the credential committees do have policies which the providers need to participate in the periodic credential updates as well as reviews to keep the status current.

There are a lot of companies, such as medical practice consultants, specializing in the provider credentials. Such companies would consult with the medical facilities and the provider practices in order to monitor and also ensure that the physicians’ credentials are kept updated and current.

Cite: What Almost No One Knows About Enrollments