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The Handbook for Credentialing Healthcare Providers

The Handbook for Credentialing Healthcare Providers


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Ellis M. "Mac" Knight, MD, MBA, FACP, FACHE, FHM

This handbook enables your organization to systemize the tedious, ongoing, and mandatory process of credentialing your medical staff - and to understand why you must!

Healthcare organizations lose substantial revenue when providers on their medical staff are not properly credentialed. Payers have unique requirements for providers to satisfy before they will pay for services.  Hospitals often face difficulty in getting the information from the provider and are challenged by a lack of systems for initial and ongoing verification and documentation.

Administrators must weigh the cost benefits of in-house or outsourced credentialing and evaluate the options for software and other tools.   Readers who use this handbook will feel confident and secure in their knowledge.

Healthcare organizations must have credentialed medical staffs to deliver their services. The reasons are two-fold: First, educated, licensed, experienced, and proven caregivers ensure that a hospital or medical practice is capable of delivering quality care. Secondly, payers require that the physicians and other licensed healthcare professionals are qualified and licensed to work with their patients. Before receiving payment for services, the provider must have specific credentials for providing that service.

Verifying and documenting the credentials of a healthcare provider is tedious, ongoing, and mandatory. An organization with a large medical staff may struggle with keeping the credentialing function current, as many licenses have rolling expirations.

Credentialing ensures that clinical practitioners are duly qualified, licensed, and board certified. It reports the history of malpractice claims, state-instituted sanctions, or other undesirable professional circumstances of providers.

Credentialing and privileging of healthcare professionals protects patients and hospitals by minimizing the risk of medical errors that may result from the work of incompetent providers. It also undergirds the reputation and credibility of the institution in the eyes of providers and across the healthcare community.

Further, credentialing with insurers forms the basis for reimbursement for professional services. Without the acceptance of the professional credentials of a provider, insurers and other third-party payers will not compensate his or her claims.

The purpose of this book is to explain the necessity and to provide the process for the official documentation of each practitioner.   The information presented in these chapters will serve as a practical resource for strengthening your organization’s credentialing function.

Book Features!
  • Outlines the necessity for credentialing in the delivery of care and in attaining reimbursements for services provided
  • Explores options for in-house and outsourced credentialing function
  • Provides systematic process for ongoing credentialing operations

If you are unclear about the program requirements, confused about how to start, are having difficulty knowing which measures to report, or you don’t understand how PQRS reporting will affect your future reimbursements, this book is for you.

TABLE OF CONTENTS

Table of Contents
Chapter 1: Credentialing - The Foundation for Quality and Safety
Chapter 2: Types of Credentialing
Chapter 3: The Pros and Cons of Outsourcing Credentialing
Chapter 4: Regulatory Requirements
Chapter 5: Automated Payer and Medical Staff Credentialing System
Chapter 6: Training for the Credentialing Function
Chapter 7: Conclusion - The Importance of the Credentialing Process
Mac Knight

Ellis M. “Mac” Knight, MD, MBA, FACP, FACHE, FHM
Dr. Knight is senior vice president and chief medical officer of Coker Group and he oversees Coker Group’s hospital strategy and operations services.  He has a particular interest and expertise in population health management, clinical care process design, cost accounting, and hospital-physician integration.  Before joining Coker, Dr. Knight served as the chief physician and clinical integration officer for Palmetto Health in Columbia, South Carolina, where he oversaw Palmetto Health’s employed physician network and helped to develop and manage their clinical integration program.