Professional capstone project and outcomes

Professional Capstone: Credentialing

Introduction

One of the most crucial processes in the realm of healthcare happens to be the process of credentialing. To a large extent, this has got to do with the assessment of the capabilities and competencies of healthcare workers such as physicians and nurses. However, it would be prudent to note that credentialing involves much more than the conduction of background as well as education checks. This write-up will focus on the various aspects that ought to be taken into consideration when undertaking physician credentialing. More specifically, the credentials that ought to be maintained and the relevance of maintaining the said credentials will be explored.

Discussion

Physician Credentialing Defined

In basic terms, physician credentialing has got to do with not only the collection and organization, but also the verification and upkeep of the various records or ‘credentials’ with the overall goal of ensure that physicians are qualified, competent, and capable of effectively executing their mandate (Safian, 2014). Physician verification could be conducted via the primary source verification (PSV) process. In this case, the person or department charged with credentialing contacts the original source with the intention of establishing whether the information supplied or represented by the physician is accurate and/or valid.

However, as has been indicated in the introductory section, credentialing involves much more than the conduction of background as well as education checks. It could be considered a way of ensuring that the various standards of safety are observed and maintained in a medical facility. As Langeabeer and Helton (2016) indicate, it is also a way of establishing professionalism and reining in medical errors. Further, the process is a requirement for compensation purposes, i.e. in relation to accessing reimbursement from insurance entities (Langeabeer and Helton, 2016).

Credentials that Must be Maintained for the Physician

As has been indicated elsewhere in this text, one of the factors taken into consideration in credentialing is whether the information that the physician supplies to the facility is complete, accurate, and legitimate. Towards this end, Pozgar (2019) observes that some of the information subject to verification could be inclusive of, but is not limited to; career or work history, qualifications, specialty certificates, board certifications and licenses, residency, as well as education and training. Other data that could be of relevance on this front is professional references, malpractice insurance, and hospital privileges.

Why Credentials Must be Maintained

Credentials must be maintained for a number of reasons. To begin with, it is important to note that the maintenance of irrefutable documentation could be considered a way of demonstrating and advancing professionalism in a medical facility. Indeed, in the words of Langeabeer and Helton (2016), “through a standardized process involving data collection, primary source verification and committee review by health plans, hospitals and other healthcare agencies, patients are assured of their healthcare professional\'s merit and experience” (131). Towards this end, the maintenance of credentials by a medical facility is, as the authors further indicate, also perceived to be a risk management and patent safety issue. As a consequence credentialing must extend beyond mere education and background checks.

At the macro level, credentialing is also considered a way of reining in fraud. It is for this reason that Medicaid and Medicare enrollment physician credentialing requirements were increased by the Affordable care Act. Towards this end, the various accreditation agencies, state governments, as well as the federal government require physician credentialing.

It is also important to note that physician credentials must be maintained so as to ensure that the medical facility accesses reimbursement from insurance entities. This is more so the case given that when it comes to compensation, medical credentialing proof is required by Medicaid and Medicare as well as private insurance entities (Showalter, 2020).

Failure to Complete Credentialing Process in a Timely Fashion: Consequences

a) Facility

Failure to complete the process could cost the medical facility financially. This is more so the case given that as Showalter (2020) points out, a facility that fails to partake in credentialing may not be able to access reimbursement from insurance establishments for the various services provided. This effectively means that a facility that does not complete the process in a timely fashion would find it impossible to access reimbursement from Medicare/Medicaid. Credentialing delays could also result in exclusion from programs funded by the federal government and possibly attract penalties and fines (Showalter, 2020).

b) Employees

The disruption of a medical facility’s billing and revenue cycles, i.e. as a consequence of claim reimbursement delays, could have a negative impact on employee wellbeing. This is more so the case when it comes to salaries and compensation. Credentialing delays could also affect hiring of new employees – resulting in work-related stress and employee burnout.

c) Clients

As has been indicated elsewhere in this text, physician credentialing also happens to be a patient safety issue. This is particularly the case given that thanks to credentialing, it is possible to establish whether physicians have the necessary skills and capabilities to perform their duties. Thus, non-adherence to credentialing requirements or failure to conclude the same in a timely manner could be a threat to patient safety.