The National Committee for Quality Assurance (NCQA) has established standards and guidelines for how healthcare facilities should go about credentialing healthcare providers. The process is important for many reasons. Aside from the assurance patients receive high level medical care, various accrediting bodies and third-party payers like Medicare and private insurers require healthcare facilities complete the credentialing process.
How does credentialing work?
The medical credentialing process is essentially a review of academic and clinical qualifications before an employer onboards a new physician. The healthcare institution or licensing board conducting the credentialing process checks the primary source for education and training — a copy of a degree is not enough to satisfy this requirement.
The credentialing process will also involve a review of the National Practitioner Data Bank. The NPDB is a program that gathers data about healthcare providers. It includes negative complaints, loss of privileges, suspension, or revocation of a medical license as well medical malpractice suits.
How often do I need to go through the credentialing process?
Any major change in positions will likely trigger a new credentialing process. The process is also often done at regular intervals every couple of years.
What can go wrong?
The process is thorough and can stall if there are instances of poor program evaluations, a high number of professional liability actions, short tenure at multiple practices or evidence of unprofessional conduct or substance abuse.
Healthcare facilities may also become aware of a physician who is providing services outside of their scope of training, potentially triggering a medical board investigation.
What should I do if credentialing results in questions from a potential employer or medical board?
It is often wise to reach out to legal counsel to review the questions and discuss the best course of action. In some situations, simple clarification is sufficient. In others, a more robust approach is wise to help better ensure your medical license is not threatened.
Attorney John Rivas is responsible for this communication