The Credentialing process exists in three parts
1. Gather Information
A healthcare facility or health insurance plan asks the provider for information on his or her background, licenses, education, etc. The provider may submit the information in a questionnaire through email or through software.
In some cases, the healthcare facility or insurance company works with a third-party company — called a credentials verification organization (CVO) — that works with the provider to gather and verify information. Organizations often hire CVOs to allow for more efficient credentialing.
2. Check the Information
In many cases, the facility or insurance company will do the background work. They will directly correspond with licensing agencies, medical schools, and other entities to verify the provider’s information.
In other cases, the facility or insurance company may use credentialing software to continuously check information that licensing agencies and other entities make available online. The CVO may also run verification checks.
Many healthcare organizations use collaboration and work management platforms to help them organize and record provider information and get automatic updates when certain credentials expire or need to be re-checked.
In all cases, the checks include monitoring reports about medical incidents, malpractice claims, or other information that could raise questions about whether to credential or re-credential the provider.
3. Award the Provider with Credentials
After the organization verifies all required credentials and finds no negative issues, the healthcare facility awards credentials to the provider.
After the health insurance company completes a similar process, it can decide to approve the provider as an in-network provider. That is, the insurance company will pay the provider for treating patients who have its insurance.
You can begin to process insurance from your patients through the approved providers. It sometimes feels daunting but truly a core part of the health care system