Ensuring Compliance and Quality in Provider Credentialing

clinical hospital

Provider credentialing is an essential part of receiving reimbursement from insurance companies and ensuring high-quality healthcare for your patients. When you hire a practitioner, you need to arrange credentialing to make sure that they are qualified for the work they are about to do at your organization.

Many healthcare facilities don’t have the experience, time, and resources to handle the complex credentialing process. They choose to outsource it to third-party organizations, such as CVO (credentials verification organization).

A team of specialists who focus on credentialing can streamline the process and help the healthcare facility save time and money. Besides arranging initial credentialing, CVO can monitor deadlines and arrange timely re-credentialing.

How Does Quality Provider Credentialing Work?

High-quality provider credentialing covers all aspects of the credentialing process and ensures smooth enrollment of the demanded professionals. If a healthcare professional is starting to work at a new practice or going across state lines, they have to undergo the credentialing process no matter how many times they have done it before.

The key phases of medical credentialing include:

  • Checking credentials – the healthcare organization checks the qualifications and credentials of the practitioner to make sure they suit their desired position. In some cases, this is called primary source qualification.
  • Providing privileges – once the credentialing process is over (depending on the situation it can take up to 6 or 9 months), the healthcare organization provides the practitioner permission to work in the position they are hired for.
  • Enrollment – the process of enrolling the partitioner into the network to receive reimbursement from the insurance company.

High-quality provider credentialing involves a comprehensive study of the partitioner’s background, reference check, and documentation processing. The goal is to make sure that the doctor received the necessary training and has the experience stated in the CV.

Low-Quality Credentialing

If the credentialing isn’t arranged by professionals, it’s easy to miss important pieces of data and end up working with a practitioner who either doesn’t get reimbursed properly or makes significant mistakes and causes lawsuits.  

With the wrong approach to credentialing, everyone is at risk. The healthcare organization can incur penalties and deal with medical malpractice lawsuits. The partitioner can face lawsuits and reputational issues. Meanwhile, patients may not get the care they deserve.

Medical Students

What about medical students? While the practitioner-to-be is still a medical student or a resident, they don’t require credentialing but only as long as they provide services allowed in their training program. This is possible because they are always under professional guidance.


Re-credentialing is an integral part of the quality and compliant credentialing process. The majority of credentialing requires renewal once every three years. This is necessary because the world of medicine is constantly changing and doctors have to make sure their skills are up to date.

The healthcare organization needs to monitor the documentation and arrange re-credentialing timely. Otherwise, they could lose valuable time and keep the practitioner from continuing their work.

Common Mistakes During the Provider Credentialing and Enrolled

If you are handling credentialing on your own, you could be making some of the most common mistakes. This could interfere with the process and lead to delays, or worse, compliance issues.

Not Enough Information About References

medical documents

One of the best ways to get a full understanding of the practitioner’s abilities and experience is to speak to someone who used to work with them. If these people saw the provider in action recently, they can share valuable information for the credentialing process. These people can include:

  • Fellowship program director
  • Department chief
  • Chief resident from the residency program

Getting the references you need can be a challenge because educators and doctors are often busy. Meanwhile, legal concerns make it harder to obtain direct references. At the same time, clinicians may not be willing to put the information in writing, especially if there were problems with the practitioner in the past.

Making a call can help you get high-quality information and allow you to ask a variety of questions instead of getting short-form written pieces. It can also be helpful when you need to check for red flags.  

Automatic Enrollment in All Branches

The high cost of working out of the network keeps the majority of patients with in-network providers. As a result, they take advantage of the network directories. Providers try to get into these directories to receive a large volume of patients. However, The Centers for Medicare & Medicaid Services (CMS) reports that group practices automatically enroll each practitioner in all branches on a group level. It means that the practitioner may never show up at some sites but be listed there as a doctor.

When the patient tries to get the demanded services and receives a response that the chosen provider isn’t available, the healthcare organization can eventually face a penalty.

The inaccurate online provider directories are becoming a red flag for the CMS. You need to make sure that your healthcare facility lists the providers accurately without automatically enrolling them in all service locations.

Getting Credentialing Right

To make sure your credentialing process is done right, you need professional assistance. You can either train specialists to arrange credentialing in-house or outsource the process to a third party. By learning more about how CVO credentialing works, you can make an educated decision about streamlining your credentialing responsibilities.

Either way, you are responsible for monitoring the credentialing process and making sure all partitioners in your organization are enrolled properly.