By getting through medical school and residency, you prove that you have one important character trait: perseverance!
You will need this trait as you wade through the mire of paperwork necessary to begin practicing your profession, and you will continue to need it throughout your career. Highlighting this point in his article, Completing the Important Practice Paperwork, Dr. Peter Alguire explained, “Physicians must produce documentation of their medical credentials over 50 times during an average career.” Credentialing is both tedious, time consuming, and critical to beginning your work.
While seemingly overwhelming, you can conquer this mountain. By understanding the process and diligently managing your communication with the parties involved, credentialing simply becomes another part of the job. To help you with the process, CareerPhysician has prepared the following helpful sections on credentialing:
• What Is Credentialing?
• Who Needs My Credentials?
• How Do I Manage the Credentialing Process?
You’ll want to be sure to pay close attention to timelines as you review this article. The entire process can take a long time, and you don’t want to delay your start date with paperwork issues.
If you are an international resident, preparing this paperwork may be even more complicated. We have added a section in this article with special considerations for that very purpose.
What Is Credentialing?
Credentialing is the process of giving evidence of your medical capabilities to the organizations that give you authority to and/or pay for you to practice medicine. Credentialing is actually a good thing. It ensures that only qualified individuals are allowed to practice, minimizing liability for hospitals and healthcare organizations. Credentialing is also good for you. Why? Credentialing seeks to weed out incompetent physicians, helping to maintain the trust of the community and, more specifically, your patients.
Credentialing unusually involves providing the following types of information:
• Current curriculum vitae
• Current state medical license
• Current Federal DEA certificate and applicable state controlled substances license
• Current malpractice insurance certificate
• Educational Commission for Foreign Medical Graduates (ECFMG) certificate (if applicable)
• Current CMEs
• Board certification (if applicable)
• Medical diploma
• Internship, residency, and fellowship certificates
• Passport-size photo
Who Needs My Credentials?
Generally speaking, three organizations need to see your credentials before you can begin practicing:
• State Medical Board
• Managed Care Organizations
The above list is actually in order. Hospitals only grant you privileges if you have your state medical license. Furthermore, managed care organizations will only allow you provider status if you have privileges at one or more hospitals. This article focuses on the latter two organizations: Hospitals and managed care organizations.
To learn about becoming certified with a state medical board, see the CareerPhysician article State Licensure.
Because of the above dependencies upon each other, this process can take a long time – even up to an entire year. So, once again, be reminded of the importance of starting early and remaining diligent throughout the process.
How Do I Manage the Credentialing Process?
Very carefully. In fact, it would be a good idea to start by preparing yourself to manage the massive amount of communication you are about to undertake. One good way to do this is by creating a Journal of Contacts like the one CareerPhysician advises residents and fellows to use for state licensure.
Download the Journal of Contacts from the Resources and Tools section. This chart helps you stay organized as you keep a record of contacts made to secure documentation for credentialing from a wide variety of sources.
Once you are ready to manage your credentialing communications, you are ready to do some planning. Use the following process as a foundation for managing your credentialing process:
1. Be aware of the timelines
2. Consider your credentialing options
3. Apply with hospitals
4. Apply with managed care organizations
5. Remain diligent and detailed
Be Aware of the Timelines
Remember that credentialing with each of these organizations is dependent upon the credentialing of the previous organization in the list. Also seriously consider the following average times it takes to process with each of these organizations:
• State Medical Board, 2-4 months
• Hospitals, 2 months
• Managed Care Organizations, 6-12 months
Consider You Credentialing Options
When going through this process of applying for credentials, you actually have some options:
• You can handle the process yourself.
• You can enlist the help of the practice, hospital, or academic institution you are joining.
• You can turn the task over to a professional service.
Doing it Yourself
When you tackle the credentialing process yourself, you take on the responsibility of requesting information, managing all communications, and filling out a number of exceedingly long and redundant forms. This is obviously the most tedious approach. However, you are in control, and the price is right.
Doing it With the Help of Your Hiring Organization
Some larger medical groups have delegated credentialing, which means that a particular health plan has delegated the credentialing process of a new physician to the group. If your new employer has delegated credentialing with health plans, your approval process will be shortened significantly. Not only is this beneficial to you, but it is also beneficial to the organization you are joining. The reason is simple: the quicker you are credentialed, the quicker you have access to the patient base and, consequently, bring in revenue for the group.
In any case, exploring the services of your hiring organization can provide some time and, potentially, cost-saving help.
Enlisting a Professional Service
Some companies offer services whereby you enter information once, and they apply for the credentials on your behalf, remind you of expiring licenses, and the like. This can be extremely convenient, but the questionnaires can also be incredibly long. For example, one questionnaire has over 800 questions!
Furthermore, you will have a long list of organizations from which to choose. In Physician Credentialing Heats Up, Maureen Glabman pointed out that “while a handful of credentialing verification organizations, or CVOs, existed in 1990, today there are an estimated 250.” The two companies mentioned below are probably good places to start if this sounds like something that’s right for you.
The Federation Credentials Verification Service (FCVS) from the Federation of State Medical Boards is one such service, as is The Universal Credentialing DataSource system developed by the Council for Affordable Quality Healthcare. The AMA also has a fairly inexpensive service, but does not cover all specialties. See the Learning More section at the end of this article for more details.
It may be well worth your investment to enlist a credentialing service because getting to your sources of information may be more complicated. On the other hand, if you still have family members in your home country, it may be extremely useful to send requests for documents to them and let them physically carry documents to each institution. Also, as you correspond overseas, be sure to use an expedited mail service that can be tracked (such as Federal Express).
Apply With Hospitals
To obtain hospital privileges you will need to complete an application. The application will include a request for the documentation listed earlier in this article as well as a number of other questions. Any affirmative answer to questions regarding claims, suspensions, sanctions, or drug impairment on the application will require an explanation. Also, periods of time unaccounted for during training will also require a written explanation. Some doctors have actually had their process slowed down by failing to mention that they were on vacation for the month following the end of their residency.
The minimum length of time from application to full approval of privileges in most hospitals is three months. During that period of time, all of the information provided on the application will be verified in writing, references will be requested, and a report will be obtained from the National Practitioner Data Bank. When all of the verifications have been received, the completed file is sent to the Credentials
Committee for approval.
Once approved, the file will go to other required hospital committees, which varies by hospital, until final approval by the Medical Executive Committee or the Board of Trustees. You will be notified in writing when your privileges have been approved.
Apply with Managed Care Organizations
As mentioned earlier, most managed care plans require that a practitioner have a state medical license and privileges at a participating hospital before they accept an application. The required procedure to process a managed care application is similar to that of a hospital application. Keep in mind that if you apply prior to completing a fellowship, the managed care plan cannot complete the credentialing process until the fellowship is finished and has been verified.
Seek assistance from your new employer in facilitating the application and approval process. You will need to provide much of the same type of information that is required for state licensure. If you have created a professional file, make a copy for your new employer so that they can begin the application process on your behalf.
Once again, some larger medical groups have delegated credentialing. If your new employer has delegated credentialing with health plans, your approval process will be shortened significantly.
Remain Diligent and Detailed
Throughout the credentialing process, be sure to follow up and be on top of the various timelines. Check in periodically to ensure that documentation you requested was actually forwarded. Universities, for example, may need to be checked on. Some experts also recommend periodically checking in with the licensing organization to check on the status and ensure things are moving along smoothly. Use the Journal of Contacts to help you stay organized in this matter. With diligence and attention to detail, you can ensure that you are credentialed and ready to practice when your start date arrives.
The following online references were used as sources for this piece. To read these articles in full, see the links that follow.
Credentialing Made Easy
By Wayne J. Gulielmo
Wayne Gulielmo is a senior editor with Medical Economics. Gulielmo describes the Universal Credentialing DataSource system, developed by the Council for Affordable Quality Healthcare. He covers how it works, which health systems are supported by the system, security, as well as which states are currently covered by the system.
H-230.972 Physician Credentialing and Privileging
This brief article discusses the AMA’s position on credentialing.
H-230.978 Physician Assignment
This is a short policy statement about physician assignment and Medicare.
Managed Care Credentialing Of Physicians
By Jerry S. Sobelman, CPA
Jerry S. Sobelman, CPA, is a principal of Margolis & Company P.C. In this article, Sobelman explains what credentialing is, why we need credentialing, and what is entailed in the process. Also discussed are risk management, accreditation, and immunity under the Health Care Quality Improvement Act (HCQIA). Finally, Sobelman points out the positive marketing effects that a well-established credentialing policy can have for managed care organizations.
Impact of Quality Trends On Physicians
By Rebecca Anwar, Ph.D. & Judy Capko
Rebecca Anwar, Ph.D., and Judy Capko are senior consultants with The Sage Group, Inc., a national healthcare consulting firm. In this article, Anwar and Capko stress the importance of quality in how patients choose doctors as well as in how employers choose health plans. The article also covers some of the quality indicators by which healthcare organizations are judged.
Physician Credentialing Heats Up
By Maureen Glabman
Maureen Glabman originally wrote this article for the ACP Observer. Glabman covers some history on the development of credentialing verification organizations, or CVOs. The article also lists and gives contact information for all the organizations that collect and distribute physician information (sort of like credit report agencies, except for doctors).
As Glabman says, “From for-profits to the AMA, everyone wants to dig into your background-sometimes for a price.”
Obstacles Hurting States’ Efforts to Revamp Physician Credentialing
By Bryan Walpert
Bryan Walpert is a freelance writer in Denver. Walpert paints a picture of the difficulties states were having trying to streamline the credentialing process. Originally published in 1999, this article is somewhat dated, but still gives a great reference as to where we have come from in terms of simplifying the credentialing process.
Don’t Be Misled by the Hype: Credentialing — Important, but Difficult
Frank Diamond is a senior editor of Managed Care Magazine. This article discusses the variation in credentialing between states, how laws differ, as well as some of the tension that exists between state medical boards and credentialing organizations, which resulted from credentialing organizations accusing medical boards of letting inadequate physicians through the licensure process. Diamond also includes a recipe for credentialing to help organizations that need to verify the quality and eligibility of their medical staff.
Completing the Important Practice Paperwork
by Patrick C. Alguire, MD, FACP
Director, Education and Career Development, ACP
Dr. Patrick C. Alguire is the Director of Education and Career Development for the American College of Physicians. Alguire thoroughly covers the mass of paperwork needed to get through the credentialing process. He also includes a brief discussion of insurance numbers and federal employee identification numbers (if you are starting your own practice) that were not included in our discussion.
CAQH At Work
Council for Affordable Quality Healthcare
CAQH, the Council for Affordable Quality Healthcare, is a not-for-profit alliance of America’s leading health plans and networks, committed to improving the quality of healthcare and reducing administrative burdens for physicians, patients, and payers. In this article, the CAQH describes how their Universal Credentialing DataSource System works. A demo is also available.
Educational Commission for Foreign Medical Graduates
Through its program of certification, the Educational Commission for Foreign Medical Graduates (ECFMG) assesses the readiness of international medical graduates to enter residency or fellowship programs in the United States that are accredited by the Accreditation Council for Graduate Medical Education (ACGME).
Federation Credentials Verification Service
Federation of State Medical Boards
The Federation Credentials Verification Service (FCVS) was established in 1996 to provide a centralized, uniform process for state medical boards as well as private and governmental entities to obtain a verified, primary source record of a physician’s core medical credentials. This service is designed to lighten the workload of credentialing staff and reduce duplication of effort by gathering, verifying, and permanently storing credentials in a centralized repository for physicians and physician assistants. You can access more information from the Federation of State Medical Boards’ home page by clicking Credentials Verification Service in the left navigation column.
About the Author:
Wesley D. Millican, MBA, CEO and Physician Talent Officer of CareerPhysician Advisors, LP, and CareerPhysician, LLC, provides comprehensive talent solutions for academic children’s hospitals, colleges of medicine and academic medical centers across the nation. He possesses a longstanding passion for career development of all young physicians and serves as a go to career resource for training program directors and their residents and fellows. In continuing his commitment to the “future of medicine”, Mr. Millican speaks nationally at residency and fellowship programs. His Launch Your Career® Series is a proven resource for today’s residents and fellows and has served as a go to resource for program directors over the last 15 years.