Avoid 8 Common Physician Credentialing Pitfalls

Deviating from physician credentialing best practices puts healthcare organizations at risk for claims of negligence.

Although physician credentialing may seem like a tedious administrative task, poor executions can result in serious consequences such as fines, delays in claim reimbursement, exclusion from federal programs, and harm to patients.

Credentialing lapses can expose healthcare organizations to malpractice suits and accreditation problems. Deviating from physician credentialing best practices—obtaining, assessing, and verifying a clinician's credentials—puts healthcare organizations at risk for claims of negligence.

Verisys, a SaaS platform specializing in provider data management, provider credentialing, and compliance, has identified eight common physician credentialing weaknesses.

1. Relying on limited staff and administration: Credentialing includes verifying a clinician's education, medical training, residency, licenses, and certifications issued by a board in the physician's area of specialty. Health systems or hospitals may not allocate adequate resources or staff to complete the medical credentialing process, which can result in lost revenue and overworked staff who are more likely to make mistakes.

2. Incomplete physician enrollment applications: The average physician enrollment application requires a vast amount of information and data. Failing to accurately fill out the application in its entirety causes delays in reimbursement and denial of claims.

3. Allowing physicians to treat patients before credentialing is completed: Courts have ruled that hospitals can be held liable when a physician falsifies credentials or begins practicing before credentialing has been completed.

4. Not updating and verifying information: Physicians need to renew their licenses and credentials on a regular basis, according to the laws of the state in which they practice. Initial credentialing and recredentialing ensures that physicians are up to date with their board certifications and licenses. When hospitals fail to stay on top of recredentialing, it could lead to physicians and facilities performing services they are not certified or licensed to perform, which can lead to malpractice lawsuits.

5. Covering up prior adverse action: Failing to disclose an adverse action is a serious oversight by any physician, but it is also the responsibility of a healthcare organization to conduct screenings for prior disciplinary actions with a thorough background check. Healthcare organizations should verify credentials against an array of databases such as the Office of Inspector General exclusion list.

6. Failing to report adverse actions: Physicians are required to report adverse actions such as license revocation; exclusion from third-party programs; and suspension or voluntary relinquishment of medical staff membership or clinical privileges. Healthcare organizations can be held accountable for a physician's omission.

7. Failing to report adverse actions to the National Practitioners Data Bank (NPDB): Physicians and healthcare organizations that fail to report adverse actions to the NPDB withhold critical information needed to complete medical credentialing. The NPDB requires reporting of the following actions: medical malpractice payments, federal and state licensure and certification actions, adverse clinical privileges actions, adverse professional society membership actions, negative actions or findings by private accreditation organizations and peer review organizations, healthcare-related criminal convictions and civil judgments, and exclusions from participation in a federal or state healthcare program such as Medicare and Medicaid exclusions.

8. Failing to take peer review activity seriously: Information provided in a peer review or investigation should be taken seriously and be evaluated as part of the credentialing process. Peer references can inform the capabilities and competencies of a physician that cannot be determined from simply checking education, training, or license status.

Chief medical officer perspective

Physician credentialing is an essential function at health systems and hospitals, and CMOs should be engaged in the process, says Andy Anderson, MD, MBA, executive vice president and chief medical and quality officer at RWJBarnabas Health.

"Having a rigorous process and procedure around physician credentialing ensures the highest levels of quality, safety, and service in the healthcare environment," he says. "The credentialing process is essentially a crosscheck on training and past work experience to support the granting of privileges to practice in specific areas in the healthcare setting. A CMO has to be someone who monitors, shepherds, and supports that process to ensure that the highest level of quality, safety, and service is attained."

RWJBarnabas ensures that the health system has adequate resources and staffing for physician credentialing, Anderson says.

"We maintain a staffing model that ensures the work gets done at the highest levels of service and quality," he says. "We monitor areas such as turnaround time, and we also get feedback directly from our physicians on the credentialing experience. We have a talented group of subject matter experts in our medical staff office who oversee the credentialing process. We make sure they are fully supported."

RWJBarnabas ensures that physician enrollment applications are complete and that credentialing information is updated and verified, Anderson says.

The health system has a software system that makes sure every element of the process is completed and all requirements are met, he says. Additionally, RWJBarnabas has a quality control process for physician credentialing that goes back and audits and crosschecks to make sure that everything is completed and accurate. The medical staff leadership reviews and approves applications once they are complete and accurate.

At RWJBarnabas, it is nearly impossible for physicians to treat patients before credentialing is complete, Anderson says. Physicians are not activated in the electronic health record to be able to practice until the credentialing process is completed and approved by the leadership of the medical staff, he says.

The health system takes great care in handling adverse actions such as license revocation as part of the credentialing process, Anderson says.

"Any issues such as a history of license revocation are taken into full consideration as part of the assessment of an application to our medical staff," he says. "For physicians who are already on the medical staff, we follow all state laws and regulations, and we report all adverse actions to the New Jersey licensing boards. We take these issues seriously. We also want to be fair with the physicians; but in the end, we must protect our patients and the public."

Peer review as part of the physician credentialing process is also taken seriously. Anderson says.  

If there is an issue that has been raised about a patient care case, typically a hospital CMO will conduct fact-finding and determine whether a peer review is necessary, he says. An independent peer is brought in to look at the patient care case and provide unbiased input, so the health system can understand why the physician chose to behave in a certain way. If a patient care case raises serious issues, it can adversely affect a physician's credentialing, he says.