Physician Credentialing is the process of organizing and verifying a doctors professional records.

Hospitals and similar organizations have a legal responsibility to verify provider’s identity, education, work experience, malpractice history, professional sanctions and license verifications to protect patients from unqualified providers.

When a doctor applies to practice within a Hospital, a Surgery Center or a Physician Organization, they are asked to complete an application and allow a credentialing entity to research their professional documents. 

For a doctor, the National Provider Identifier (NPI), CAQH Proview, professional licenses, diplomas, certifications, and professional references are all considered credentialing documents. The process of credentialing is to verify the accuracy and specific data in your documents.

At a minimum, the credentialing agent will request a copy of your National Provider Databank file and possibly request a credit report and criminal background search.  They will also do what is known as Primary Source Verification. This is the process of requesting and receiving verification of your stated credentials from the College or other entity that issued the diploma or certificate.

The Affordable Care Act has substantially increased physician credentialing requirements for Medicare and Medicaid enrollment in an effort to reduce fraud and abuse. Insurance plans must meet increased credentialing requirements including periodic re-credentialing and attestation.

As a physician, it is very important that all documents are accurate and all match.  Problems begin when there are inaccuracies and discrepancies between various records. It is a good idea to contact your references before they receive a reference request, as problems can occur when professional references do not respond in a timely manner.