Provider credentialing is the process of verifying and evaluating the qualifications and credentials of healthcare providers, to ensure they meet the necessary standards and regulations for their respective roles. Following provider credentialing best practices can ensure consistency and accuracy throughout the entire process. Provider credentialing best practices include standardizing the process, verifying all credentials, performing ongoing monitoring, and maintaining accurate records

1. Legion’s Guide to Provider Credentialing Best Practices

2. Call us at: 727-475-1834
Email us at: kbradley@legionhealthcaresolutions.com
Legion’s Guide to Provider Credentialing Best Practices
Provider credentialing is the process of verifying and evaluating the qualifications and credentials of healthcare
providers, to ensure they meet the necessary standards and regulations for their respective roles. Following provider
credentialing best practices can ensure consistency and accuracy throughout the entire process. Provider credentialing
best practices include standardizing the process, verifying all credentials, performing ongoing monitoring, and
maintaining accurate records. Before we understand all these steps in detail, let’s define provider credentialing.
Defining Provider Credentialing
Provider credentialing is the process of verifying and evaluating the qualifications, experience, and licensure of
healthcare providers, such as physicians, nurses, and allied health professionals. This process is necessary to ensure that
healthcare providers meet the standards of quality and safety set by regulatory bodies, insurance companies, and
healthcare facilities. Provider credentialing involves verifying a range of information, such as a provider’s education and
training, licensure and certification, work experience, malpractice history, and professional references.
Information required for provider credentialing is typically gathered through a combination of primary source
verification, such as checking with licensing boards and educational institutions, and secondary source verification, such
as reviewing resumes and professional references. Once a healthcare provider has been credentialed, they are typically
granted privileges to practice in a particular healthcare facility or with a particular insurance company. Provider
credentialing is an ongoing process, as healthcare providers must maintain their licensure and certification and meet
continuing education requirements to remain in good standing.

3. Call us at: 727-475-1834
Email us at: kbradley@legionhealthcaresolutions.com
Legion’s Guide to Provider Credentialing Best Practices
Provider Credentialing Best Practices
Provider credentialing process is critical for protecting patient safety and maintaining the quality of healthcare services.
Following are some best practices for provider credentialing:
Standardize the Process
Establish clear and consistent processes for collecting and verifying provider information, including their education,
training, licensure, and experience. Standardizing the process is a best practice in provider credentialing because it helps
to ensure consistency and accuracy throughout the entire process. Standardizing the process involves creating a set of
defined procedures, criteria, and guidelines for each step of the provider credentialing process. These can include
verifying the provider’s education, licensure, work history, malpractice history, and other relevant information. By
standardizing the process, healthcare organizations can ensure that each provider is evaluated using the same criteria,
regardless of who is performing the evaluation.
Key advantage of standardizing the provider credentialing process is that it helps to identify and address any
inconsistencies or discrepancies in the provider’s qualifications or credentials. For example, if one evaluator overlooks a
red flag in a provider’s background, it could lead to a potential liability issue down the line. By having a standardized
process, healthcare organizations can ensure that all evaluators are using the same criteria and are following the same
steps, reducing the likelihood of errors or omissions. When the process is standardized, evaluators can follow a set of
established procedures, reducing the amount of time and resources needed to complete the credentialing process.

4. Call us at: 727-475-1834
Email us at: kbradley@legionhealthcaresolutions.com
4 Key Points in Legion’s Guide to Provider Credentialing Best Practices
This can help to streamline the process and reduce the overall cost of credentialing.
Verify all Credentials
Verify all of a provider’s credentials, including their education, training, licensure, board certification, and malpractice
insurance. This helps ensure that providers are qualified to practice and have the necessary skills and knowledge to
provide safe and effective care. When healthcare organizations verify all credentials, they conduct a comprehensive
review of a provider’s credentials to ensure that they meet all the necessary requirements to practice medicine. This
includes verifying their medical degree, residency training, board certification, and other relevant certifications or
licenses.
By verifying all credentials, healthcare organizations can ensure that they are hiring competent and qualified healthcare
providers who can deliver high-quality care to their patients. This practice also helps to ensure that healthcare providers
are in compliance with state and federal regulations, which require them to meet certain educational and training
standards to practice medicine. In addition to verifying credentials during the hiring process, healthcare organizations
must also periodically re-verify their providers’ credentials to ensure that they remain in good standing. This is especially
important for providers who hold time-limited certifications or licenses, as they may need to renew their credentials
periodically to maintain their eligibility to practice.

5. Call us at: 727-475-1834
Email us at: kbradley@legionhealthcaresolutions.com
Legion’s Guide to Provider Credentialing Best Practices
Perform Ongoing Monitoring
Performing ongoing monitoring is an essential best practice in provider credentialing that helps ensure that healthcare
providers maintain their competence and compliance with regulatory requirements throughout their tenure with an
organization. Ongoing monitoring involves regularly reviewing and assessing a provider’s credentials, including their
licenses, certifications, and training. This process ensures that the provider remains eligible to practice, meets regulatory
requirements, and complies with the organization’s policies and procedures. The frequency and scope of ongoing
monitoring can vary depending on the provider’s specialty, risk level, and the organization’s policies. By regularly
assessing a provider’s credentials and performance, an organization can identify and address any potential issues before
they become significant problems that could compromise patient safety or the organization’s reputation.
Maintain Accurate Records
Keep accurate and up-to-date records of all provider credentials, including documentation of verification and monitoring
activities. Accurate record-keeping is essential for several reasons. Firstly, it helps to ensure patient safety by confirming
that providers have the necessary qualifications, licenses, and experience to perform their duties effectively. Secondly, it
helps healthcare organizations to comply with legal and regulatory requirements, such as state licensing and
accreditation standards. Accurate record-keeping is also critical during the re-credentialing process, which typically takes
place every two to three years.

6. Call us at: 727-475-1834
Email us at: kbradley@legionhealthcaresolutions.com
Legion’s Guide to Provider Credentialing Best Practices
Overall, provider credentialing is a critical process for protecting patient safety and maintaining the quality of healthcare
services. Most of the times, healthcare organizations don’t have qualified resources to manage provider credentialing
process. Legion Healthcare Solutions is a leading medical billing company providing complete billing and coding services.
We can assist you in complete provider credentialing and enrollment process for various payers including Medicare,
Medicaid, and major commercial payers in your area. To know more about our provider credentialing and enrollment
services, contact us at 727-475-1834 or email us at info@legionhealthcaresolutions.com

7. Address
170 40th Ave NE, St.
Petersburg, FL 33703, USA
Phone Number
727-475-1834
E-mail Address
kbradley@legionhealthcaresolutions.com
THANK YOU