Updated on 6/28/24

What is credentialing? 

In a healthcare setting, physician credentialing is the formal process of verifying the professional records that qualify a doctor to practice medicine. The physician credentialing process includes researching their board certifications, hospital admitting privileges, education, malpractice insurance, professional references, work history, and more.

Physician credentialing is a vital safeguard for patient safety because organizations must obtain verification of the practitioner’s education, training, certificates, and licensure and maintain a file on each provider.

Why should you start the credentialing process right away?

The payor enrollment process is often the longest, most time consuming step. Giving yourself at least 90 days in advance, or even more, will give you and your credentialing team enough time to fill out and submit payor applications to avoid any delays in treating patients. By completing the longest step in the physician credentialing process first, it will allow you to begin collecting and completing the remaining credentialing to-do’s. 

Give yourself enough time in order to avoid extra stress or confusion—you should start at least 90 days in advance; you may even start even earlier, at 120, 150 or 180 days ahead of time. If a healthcare practice falls behind in credentialing, reimbursements can be delayed or denied. 

What documents do I need for the physician credentialing process?

Give your new hire a set deadline to provide the following documents:

• A fully updated CV/resume 
• Active state medical licenses
• DEA registration
• Medical school diplomas
• ECFMG certificate
• Residency, internship, and fellowship certificates
• National Provider Identifier (NPI) documentation
• Board certification(s)
• Malpractice liability insurance certification

Red flags to watch out for

Credentialing often reveals many things about a healthcare professional’s past. You should reevaluate if you encounter any of the following during the physician credentialing process, according to the National Institute of Health: 

• The reluctance of the applicant to provide permission to contact the previous employer or healthcare institution
• The reluctance of the application to provide specific references or perhaps the references are too vague
• Sudden relinquishment of licensure or medical staff membership
• Sudden loss of privileges in a hospital
• Marked gaps in clinical practice
• Short tenure at multiple hospitals
• An unusually high number of professional liability actions with the final judgment against the practitioner
• History reveals substance abuse, domestic violence, or unprofessional conduct
• History of being investigated by the state board of licensure or other healthcare organizations
• Major gaps in insurance coverage
• Evidence of poor program evaluations more than once

How BlueStone Services Can Help

The Healthcare Consulting Team at Medical Business Advisors, a division of BlueStone Services, specializes in working with physician’s practices, hospital departments, and other healthcare entities in Maryland, Virginia, and DC.

Our consultants possess a wealth of knowledge best suited to provide practice advisory solutions tailored to improve your operational and financial performance, including speeding up the credentialing process. Contact us to get started today!