What Is Physician Credentialing?

Physician credentialing is the practice in which documented recognition and verification is administered to a practicing medical professional (physician). An examination into his practices, standing and observance of relevant criterion is conducted to assess his competency and running. Furthermore, credentialing is used to confirm a physician's license, education, training, decision-making and overall quality

Significance

• The physician credentialing system is used by various organizations and agencies to ensure that their health care practitioners meet all of the necessary requirements and are appropriately qualified. The required criterion surrounding the credentialing comes from a fit and unbiased physician-controlled peer review group or committee. It's determined using general lawful, professional and executive practices that have been officially approved and must be made available to the public.

Features

• Such criteria must be connected to characteristics of patient care and treatment, as the standard of the physician's practices is calculated alongside these factors. The specifics of the criterion may slightly vary according to the physician's area of specialty and the scope of her practice. Physicians are broken down into two different types: a Doctor of Medicine (which is an M.D.) and a Doctor of Osteopathic Medicine (D.O.). Within the above, there are further areas of specialty. For example, a physician may specialize in general medicine, obstetrics, psychiatry or surgery.

Function

• In general, insurance companies (networks) and various health care facilities, require their doctors to hold and maintain the proper credentials. For a physician to participate (become a "network provider") with a provider like Medicare, he must have the necessary physician credentials and go through the Medicare credentialing process. Medicare credentialing is obligatory for a practitioner to be reimbursed from Medicare, as a physician can't bill Medicare for any of the services he provides unless he has undergone the above and received approval.

Identification

• Physician credentialing may also be conducted by other facilities, companies and associations, to appraise the subject's experience and legitimacy. Investigation into a physician's practice, training, skill level and capacity are conducted along with background checks to ensure her legitimacy. Features such as the institution she attended and graduated from, where her internship, residency and fellowship was conducted, Board Certifications and State Medical License(s) are explored, along with the individuals' professional references, liability claims history, privileges, associated memberships and status with the Department of Health and Human Services.

Considerations

• The Utilization Review Accreditation Commission (URAC) is regarded as the foremost organization that oversees the credentialing and qualification standards for those in the health care industry. Other companies like HCPro, Inc. are dedicated to providing information that's important to health care credentialing, regulation and overall administration.

  The credentialing process for a physician usually begins prior to his employment and start of practice. It's monitored and verified throughout his career in established intervals.