The physician credentialing process ensures that a doctor has met standard qualifications.
Physician credentialing is the process by which an insurance company or hospital reviews a doctor's education and employment history and determines his qualifications to practice in the medical field. This thorough review of a doctor's employment record, training and other information protects the business and its patients by ensuring physicians are properly licensed and meet the organization's high standards for service and character.
Basic Information
The credentialing bureau or insurance company first checks on the physician's general information. Every three years or longer, depending on state regulations, a doctor must sign a document stating his real name, specialties and affiliations with medical groups or hospitals. This document is filed with the Division of Professional Regulation or a similar department in the state where the physician practices. This information is available for potential employers and the medical credentialing bureau. Any information on a doctor's application to an insurance company, hospital or potential employer may be compared to listings in the National Practitioner Data Bank, The American Board of Family Medicine or other physician organizations.
Education
The physician's education and training is verified by calling and writing the colleges listed on the application. Grade point average, academic awards and research, and classroom conduct are examined. Instructors and classmates may be contacted for references. The depth of research into a physician's training differs according to the hospital or organization initiating the credentialing process.
Licensure
A physician must be licensed in the state (or states) in which she practices. Every state has slightly different procedures for granting a license, but in every case a physician must fill out an application and have graduated from an accredited medical school. The credentialing body checks that the doctor's license is up to date, and that there are no restrictions on her ability to perform medicine in that state.
Board Certification
Physicians specializing in a particular type of practice can apply for and receive board certification. This means that the doctor has passed a number of training milestones in the specialty. A board-certified doctor has graduated from an accredited medical school and trained for a given length of time in his specialty. He must also pass an examination given by the medical board in that specialty. Finally, the board-certified doctor must have practiced in her field for a specified length of time. The American Board of Medical Specialties states that board certification indicates a physician has outstanding expertise in her field.
Malpractice
The credentialing authority checks the doctor's records for malpractice suits and other legal actions. If the examiner decides that the physician has had too many malpractice issues, they may not grant a passing credential. The examiner also determines if the doctor has an adequate amount of malpractice insurance.
Prescriptions
The physician must be authorized by the Drug Enforcement Administration (DEA) to write prescriptions in the United States. The DEA or National Technical Information Service will have the doctor's name on their roster if he has not abused his prescription-writing privileges.
Work History
The doctor's work history will be verified. Colleagues may be contacted for information about bedside manner and character references. Finally, the credentialing authority will make sure that the physician can legally care for Medicare and Medicaid patients.
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