A Guide to Medical Credentialing 2022

In this article, we are going to discuss medical credentialing and the role it plays in healthcare. Being in the UK, we're going to focus on the credentialing processes required for UK based healthcare providers, but also touch on other forms of credentialing that potentially become more important as the UK looks at other health system models in the future.

What is medical credentialing?

The term medical credentialing covers a number of different forms of credential verification within the healthcare industry. Some of the more common usages of the term include:

• The verification of credentials for patient-facing medical staff
• Verifying conducted by medical insurance providers
• Controlling the access of supplier or vendor representatives

In this article we are going to explain each form of medical credentialing and the role it plays in protecting healthcare providers and patients.

Medical Credentialing: physicians and medical staff

Medical credentialing, sometimes known as medical provider credentialing, is a multi-step process hospitals and other healthcare organisations use to gather and verify practitioners’ qualifications and experience during their application to practice medicine. 

Credentialing is performed for healthcare professionals who are employed by the healthcare organisation, but also those that may be affiliated to the organisation and are patient-facing. This could be a doctor or bank nurse that provides cover or works in the community. 

The GMC (General Medical Council) has defined medical credentialing as:

‘a process which provides formal accreditation of competencies (which include knowledge, skills and performance) in a defined area of practice, at a level that provides confidence that the individual is fit to practise in that are”

Whilst the RNC (Royal College of Nursing) explains medical credentialing specifically relating to nurses as:

‘the process of assessing the background and legitimacy of nurses to practice at an advanced level through assessing their qualifications, experience and competence.’

From the patient’s perspective, the objective of medical credentialing is to protect the public and give assurance that anyone providing healthcare is doing so with the right expertise and experience to deliver healthcare safely.

In the UK, there are currently 35 regulated health and social care professions across 12 statutory regulatory bodies. These regulatory bodies are the gatekeepers to the medical professions, with each professional being required by law to register with the relevant regulatory body. 

Each healthcare organisation has to verify and later re-verify that each healthcare profession joining their organisation meets the requirements, and document that process to be able to evidence that the compulsory checks have been completed. 

DIY credentialing will usually involve a large Excel document with many sheets to track all the different components & deadlines. It will take time & significant effort. However, a credentialing service, that are experts in the process & regulations can make the credentialing process much faster & easier.This is where Credentially helps. Our industry leading software helps manage and automate components of the credentialing process, speeding up the process and saving time. For more information on our platform.

The importance of medical credentialing

Aside from the regulatory requirement to ensure all healthcare professionals employed or contracted within a healthcare organisation have had their credentials verified, there are a number of additional arguments for a robust medical credentialing process. 

Patient confidence

Healthcare organisations want their patients to have confidence in the professionals treating them. 

Patients are often in a stressed state, having peace of mind that the medical professional dealing with them has the required training and certification is not only important to the patient’s experience but also plays a role in the healing process. 

Quantifiable professionalism

Career-minded healthcare professionals want to work in the best teams, with other top professionals. Being able to present a stringent and evidenced credentialing process gives other professionals peace of mind that the people they are working with are vetted and proven professionals. This can play a role when it comes to recruiting new medical staff. 

Required for insurance

Healthcare organisations require medical staff to be medically credentialed to comply with insurances such as medical liability insurance. The NHS similarly has NHS indemnity which requires the NHS to have a duty of care to its patients, and part of the responsibility includes a strict and evidenced credentialing process. 

Reduces Medical Errors

Ultimately, the goal is to limit the number of medical errors made. Ensuring that hospitals are employing the most qualified and experienced healthcare professionals available plays a role in reducing medical errors. 

Being able to verify the level of experience and expertise being presented by an applicant is essential. 

Medical Credentialing: Vendor credentialing

Vendor credentialing is the process healthcare organisation administrators go through to vet third-party suppliers and sales representatives before they purchase medical equipment or services from them. For the protection of patients, a healthcare provider will ensure that all vendors meet the required regulations and standards.

Vendor credentialing is typically managed by the organization’s supply chain department. However, administrators of vendor credentialing can include many people within a facility - basically anyone responsible for managing access to the facility or maintaining relationships with vendors.

Although this is not the same for all healthcare organizations, many will give vendors clinical privileges. For example, a vendor or medical equipment might be given access to watch over surgery being performed using the equipment the vendor supplies.

Similar to credentialing a healthcare professional, third party representatives will require some general health and background checks. Some of the checks include:

• Proof of immunizations, including for measles, mumps, and rubella (MMR), hepatitis B, and the flu
• Proof of CPR and other certifications
• Proof of education and training in certain federal and other governmental policies
• A criminal background check
• A drug screening
• Proof of liability insurance
• Knowledge of and a promise to follow hospital policies and procedures

Although less common in the UK than in the US, vendor credentialing is starting to be incorporated into hospital policies. Part of patient care is patient safety, and verifying any third party ensures that the patient is not put at risk.

Medical Credentialing: Insurance credentialing

This is not a form of credentialing that is prevalent in the UK but rather in countries like the US, which have a private medical component to their healthcare system.

Credentialing, in this case, is also referred to as primary source verification. It is an intensive process conducted by the insurance company. They conduct a background check on the physician that delivered the treatment to verify their education, competencies and legal authorization to practice medicine.

The purpose of credentialing with insurance companies is to allow a provider to see patients with that particular insurance & then bill for services. If insurance credentialing is not completed, the physician or healthcare organisation will not be paid. It becomes an essential component of medical billing.

Summary

In the UK healthcare workers must go through a structured medical credentialing process before being allowed to work with patients. From nurse practitioner to physician credentialing, healthcare professionals must be vetted. Their qualifications and experience need to be evidenced before being allowed to work with patients.

The credentialing application and credentialing process can be resource-intensive and time-consuming. Healthcare organisations are turning to medical credentialing services and software to help speed up the process and automate as much of the process as possible. At Credentially we have helped verify the credentials of thousands of medical staff.

Check in 30 seconds if Credentially can solve your credentialing problems.