Provider Credentialing

Efficient Provider Credentialing

To provide the best possible healthcare to your patients, it is important that your healthcare providers are up to the task. But, how can you ensure that the healthcare providers you hire are competent and qualified for the job. Provider credentialing is the best way to compare, evaluate and verify the qualifications and competency of the healthcare providers that you are hiring. However, provider credentialing is no easy task – considering the quantum of information that must be collated, checked and analyzed before accepting a healthcare provider at your facility. Here are the essential steps to ensure a thorough and effective provider credentialing process.

Identify and list potential candidates

The first step is to identify available healthcare providers and approach them through a staff member to determine whether the provider would be interested in applying for credentialing. Once the healthcare provider shows his interest, a credentialing application package can be sent for the provider to fill and return.

Be specific about information required

Ensure that you provide specific instructions to the potential provider about the required information for credentialing. This could include education details, work history, certifications, licenses, malpractice liability certificate and more. You also need to ensure that the potential provider is aware of the deadlines for submitting the data.

Personal and peer references

References are a way to qualify the potential providers standing amongst their peers. Insist on at least three references from peers who are in similar field as the provider. However, none of these references should be from either family members or members of the providers practice.

Verify and check background

Verification and background check is the most crucial and time consuming part of provider credentialing. It is imperative that each piece of information given by the prospective provider is thoroughly checked and re-checked by a staff member. This can be done through the CAQH website. The areas that require verification and checks include:

  • Education history
  • Employment history
  • Current medical licensure
  • Medicare sanction information
  • Closed and settled claims history

After a satisfactory verification of the above, you need to check on the personal references that the potential provider has submitted.

Discard poor applications

Provider credentialing is expensive as it requires a staff member to sift through the information, verify and make background checks, prepare and send correspondence and follow up. This requires both time and money. It thus makes sense to weed out applications that do not match the requirements or seem unlikely to come to fruition.

Check malpractice details

A malpractice suit or settlement does not necessarily disqualify a potential provider. Ask the potential provider to explain the situation and reasons for the suit/settlement and compare the same with the providers claim history through the National Practitioner Bank.

Verify privileges

Healthcare providers applying for privileges at a hospital receive a list of approved procedures for their specialty. You should contact the providers affiliated hospitals and request for a list of privileges that the potential provider holds there. Alternately, you could also ask the potential candidate to provide documentation that proves their training for the specific procedure. This will ensure that the potential provider is trained and experienced in those procedures.

Keep track of the progress

Provider credentialing is a cumbersome task as it is, and it will do no good to the facility if critical steps or data is missed. The credentialing staff needs to keep track of all documentation and follow ups that take place. Keeping a checklist is the easiest way to do this – however, you need to ensure that the checklist is checked regularly. This will ensure that all steps taken towards the credentialing process are up to date and all follow ups are taking place as required.

Outsource the process

Provider credentialing and enrollment involves much more that just filling out forms.  It is crucial to understand the importance of provider credentialing and enrollment in relation to the revenue stream of the organization and how it affects the accurate reimbursement for services rendered. Outsourcing the job of provider credentialing and enrollment to a competent and experienced organization ensures savings in both time and money. This also leaves your staff to do what they do best – look after the patients.


  1. 8 best practices for successful credentialing. (2016, October 24). Retrieved August 22, 2017, from
  2. CAQH Launches New Solution to Improve the Provider Credentialing Process. (2017, April). .
  3. Credentialing. (2017). Retrieved August 22, 2017, from

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