Credentialing & privileging Healthcare

1. Credentialing & privileging

2. Credentialing
• It is the “practitioner's appraisal process”.
• A primary evaluation process that involves the verification of the
practitioner’s right to participate in the medical staff membership
and of his/her competency to provide patient care in the
appropriate setting.
Frequency:- every two years.
• Re-credentialing process
 It is conducted before either:
i. Re-appointment to the medical staff.
ii. Renewal or revision of clinical privileges.

3. Types of Credentialing:
Primary source verification
Centralized credentialing
Delegated credentialing
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4. Types of Credentialing:
1-Primary source verification:
required at the time of initial credentialing.
2-Centralized credentialing:
one credentialing application and one-time primary source
verification for all providers, for credentialing, re-credentialing
appointment and re-appointment.
3-Delegated credentialing:
By a Credential verification organizations
“CVOs”.

5. Who carries out the Credentialing process ?
• If the hospital carries the credentialing process by itself, the Medical
Director usually bears ultimate responsibility for credentialing along
with the Credentialing Committee.
• Delegated credentialing:
• Is the delegation of the credentialing process to a third-party called
“Credentialing Verification Organization” (CVO).
• The CVO performs primary credentialing on a physician, then
reports the results to the hospital requiring this information ..

6. When does the hospital carry out
Credentialing ?
The primary credentialing process is performed for the new
applicants; it is a critical process and should be carried out during
the recruiting period .
Periodic re-credentialing should take place, for already working
practitioners, at most every 2 years in hospitals
Re-credentialing may be less extensive than primary credentialing
but may be more sophisticated as it looks at measures of quality of
care, compliance with the organizational policies and procedures,
utilization management issues & peer review results.

7. Why Credentialing ?
• Without performing proper credentialing, the hospital will have no
knowledge of the competency of the physicians who are about to
join the clinical team and thus jeopardizing the quality of clinical
service/care provided within the facility.
• In the event of a legal action against one of its physicians, the
hospital may expose itself to some liability by having failed to carry
out proper credentialing.

8. What are the basic elements of the
Credentialing Process?
These basic elements include inquiry about;
1. Medical license
2. Specialty certification: MOST BASIC requirement.
3. Training: location, type…etc.
4. Hospital privileges: scope of practice privileges.
5. Malpractice history: pending claims, successful claims
against the physician.
6. Location and telephone # of all offices.
7. Yes-No questions regarding; suspension of privileges or
license/chronic or debilitating disease, being a smoker…etc.

9. Results of the Credentialing process
1) Delineation of Clinical Privileges Plus/minus
2) Appointment to the medical staff

10. Clinical Privileging Process:
• Definition: granting permission to provide specific medical or other
patient care services in the organization, within well-defined limits,
based on the individual’s professional license, competence,
experience, ability and judgment, and on the organization’s ability
to provide and support the service.

11. Privileging
Different
Privilege
Statuses
Approved Emergency Temporary

12. Privilege Status:
• Approved: Delineated privileges approved for the time period
specified by the organization, but never longer than two years.
• Temporary: In case of:
• The non feasibility of acquiring information about the applicant due to:
Loss of his / her record.
The primary source no longer exists.
Political reasons.

13. • When appropriate, the CEO or his / her designee may grant temporary or
locum tenens privileges for a limited period of time on the
recommendations of the director or department chairperson of a clinical
service, or the president of the medical staff in other circumstances.
• Medical staff bylaws must define the limited time-frame for which these
privileges are granted.
• Time period is specified in the bylaws, or the organization’s policies and
procedures, but it never exceeds two years
Privilege Status:

14. • Emergency:
Any medical staff member who has clinical privileges is permitted
to provide any type of patient care necessary as a life-saving
measure, provided that the care provided is within the scope of
his/her individual license, regardless of his/her credentialing status,
or approval of specific privileges.
• Limitation of Privileges:
Limitations are specified, including:
Consultation, proctoring, and requirement for a second opinion or
supervision.
Privilege Status:

15. CREDENTIALING AND PRIVILEGING
Red Flags
• Gaps / missing dates.
• Discrepancies between applicant’s information and verification.
• Previous adverse actions.
• Drug and alcohol abuse.
• Felony convictions ‫جنائيه‬ ‫.ادانه‬
• Many lawsuits pending settled.
• Cancelled malpractice insurance.
• Frequent job changes.
• Suspicious reference letters.
• Altered documents.

16. Proctoring
• The observation and evaluation of the new applying practitioner by
“Peers reviewing”.
• Acts as a part of the process of granting of the clinical privileges
(i.e.) performed during the period of “temporary privileging”