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What You Need to Understand About Physician Credentialing

The managed care insurance companies, the physician offices, the hospitals and the laboratories all credential the physicians. You have to know that credentialing is actually the act of gathering information about the doctor or medical provider to verify their qualifications when it comes to practicing medicine in their specialty.

Know that there are many agencies which actually oversee the credentialing processes. There is one leading agency that monitors the credential and the qualification standards in healthcare. It is necessary that the medical providers undergo the credentialing process before they are hired by the insurance companies or the medical facilities. Physician credentialing or medical credentialing is going to verify the training, licensure, quality, education and also the general ethical standing of the provider in a particular medical community.

The process of credentialing is going to start by submitting the required information to the credentialing agency for evaluation. The areas of focus would include the licenses, education, board certification, background check, malpractice claims, resume and the detailed work history, privileges, personal preferences, the malpractice insurance and several others.

The information gathered are going to be reviewed by a physician peer-review committee. The committees would actually make recommendations to the professional as well as the standing of the provider in the community. The committees would also evaluate the ethical behavior of the physician.

The insurance companies including the government-sponsored payers, will look for the physician’s medical credentials before accepting the professional into a group of participating providers. Those physicians that didn’t undergo credential procedures won’t be allowed to bill for services according to the policies of the Medicaid and Medicare. The managed care organizations have strict physician credentialing process prior to the listing of the provider with the insurance company. A lot of private physician practices would credential the doctors to make sure of quality care delivery.

It is through credentialing that the customers can assure that the medical providers were reviewed by the peers. This would also provide such higher level of trust and ensure that the provider is licensed and also certified and hasn’t had their licenses or their privileges revoked by the other state. But, such cannot determine the quality of the care offered by the provider. So many credential committees implemented policies that the providers must participate in like periodic credential updates and reviews to keep the status current.

There are several companies, like the medical practice consultants, which specialize in the provider credentials. Such companies would consult with the medical facilities and the provider practices in order to monitor and also ensure that the physicians’ credentials are kept updated and current.

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