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What You Need to Understand About Physician Credentialing

The physician offices, hospitals as well as managed care insurance companies and the different laboratories all credential the physicians. You have to know that credentialing is actually the act of gathering information about the doctor or medical provider to verify their qualifications when it comes to practicing medicine in their specialty.

There are a lot of agencies that oversee the credentialing processes. Know that there is a leading agency which monitors the credential as well as the qualification standards in healthcare. Medical providers must go through the process of credentialing before they are hired by the medical facilities or the insurance companies. You must know that physician credentialing or the medical credentialing would verify licensure, training, education, quality, general ethical standing of a provider in the medical community.

The process of credentialing is going to start by submitting the required information to the credentialing agency for evaluation. The areas of focus actually include board certification, education, licenses, malpractice claims, background check, resume with a detailed work history, personal references, privileges, malpractice insurance and others.

The information gathered are going to be reviewed by a physician peer-review committee. The committees would make recommendations to the professionalism and also the standing of the provider in the community. Committees are going to evaluate the ethical behavior of the medical provider.

The insurance companies, which include the government-sponsored payers, will research the physician’s medical credentials before accepting the professional into the group of the participating providers. Those physicians that didn’t undergo credential procedures won’t be allowed to bill for services according to the policies of the Medicaid and Medicare. The managed care organizations do have a firm physician credentialing process before the provider would be listed as participated with the insurance company. So many private physician practices are going to credential the doctors to ensure 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. A lot of credential committees actually have policies which the providers should be participating in like the periodic credential updates as well as reviews to update the status.

There are several companies, like the medical practice consultants, which specialize in the provider credentials. These companies consult with the different medical facilities and the provider practices to monitor and make sure that the physicians’ credentials are always updated.

Refer to: straight from the source

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