MAllen_mod4_Credentialing Healthcare Providers.

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MAllen_mod4_Credentialing Healthcare Providers.


Credentialing Healthcare Providers

Marion Allen

Rasmussen College

Healthcare Operations Management

Deborah Ryan


Credentialing Healthcare Providers

Credentialing is integral to the provision of quality health care services. Healthcare organizations operating in modern clinical practice must promote patient safety and provide care within recommended standards. Although adequate staffing is essential to organizational success, healthcare organizations must comply with the profession’s laws that govern the minimum credentials and requirements to authenticate healthcare providers’ abilities and skills. Credentialing is the formal process that scrutinizes healthcare providers’ ability to practice medicine and provide the highest level of care based on established guidelines (Patel and Sharma, 2020). Patients are entitled to access and receive quality healthcare from qualified and competent healthcare providers. Credentialing ensures that healthcare providers meet the qualifications, licensure, training, and abilities required in clinical practice. Credentialing process is standard across similar specialties. Research indicates that healthcare providers provide care with fake certificates and experience (Rubin, 2022). Such cases increase the need to be vigilant to ensure only qualified healthcare providers practice medicine.

Various accredited bodies, such as the National Committee for Quality Assurance (NCQA), have established a series of standards that guide the process of credentialing healthcare providers. One primary requirement of NCQA is to verify healthcare providers’ academic qualifications by ensuring they provide original copies of their certificate, diploma, and degree in the field. According to Patel and Sharma (2020), verification of credentials is conducted by various agencies such as the American Association of Nurse practitioners (AANP, American Board of Medical Specialties (ABMS), and National Practitioner Data Bank (NPDB). AANP verifies nurses’ credentials to ensure they are certified by the nursing board. ABMS represents 24 medicine disciplines and evaluates the American physicians’ credentials to ensure they are board certified. The agency certifies over medical specialties. NPDB is an American government program that gathers providers’ data and allows its access by authorized users. Data collected include license suspension and revocation, malpractice cases, awards, and negative complaints.

Internal and external departments conduct credentialing of healthcare providers following a systematic process. Firstly, the departments obtain healthcare providers’ data and documents from various sources (McMullen and Howie, 2020). This data includes healthcare providers’ education, license, work history, National Provider Identification (NIP) number, liability coverage, board certifications, eligibility for state regulatory requirements, and fellowships. The credentialing department should focus on documenting the evidence of the provider’s minimum credentials, including education background. The education background entails the formal qualifications required for registration by the national board and information about recognized postgraduate awards and certificates demonstrating the providers’ completion of training from a recognized training institution. For a graduate practitioner, education information includes the competencies and learning objectives of attended training programs and supervised units from the training institution. Secondly, the credentialing department verifies the healthcare provider’s information. The credentialing department liaises with licensing agencies and other entities to verify the obtained data. In the digital era, credentialing software continuously checks the provider’s information availed by empowering agencies and other entities. Most healthcare organizations collaborate with management platforms to automatically update and record providers’ information. Data verification also includes monitoring providers’ malpractice complaints and medical incidents that could affect their clinical practice. Lastly, the credentialing department awards the healthcare provider the credentials, including clinical privileges and the ability to practice onsite. Onsite visit during credentialing is vital for healthcare providers unrolled under Medicare. These onsite visits verify the provider’s existence and compliance with the set requirements regarding providing healthcare services to Medicare beneficiaries. Additionally, all healthcare providers are eligible to have an NPI (Reed, 2020). NPI identifies care providers to their healthcare partners.

Every licensed healthcare practicing independently and legalized by law and a licensing organization to provide healthcare services without direction within the scope of their license requires credentialing. Although every state varies in its medical practice laws, healthcare providers can only perform the services for which they have received the clinical privileges (McMullen and Howie, 2020). Credentialed specialties include physicians, optometrists, podiatrists, ophthalmologists, and nurses. Credentialing is not only for healthcare providers but also for healthcare facilities. Healthcare institutions are required to maintain standards of care and competence. Examples of facilities that need credentialing include dialysis, hospice care, IV home infusion therapy, ambulances, and lithotripsy.


McMullen, P. C., & Howie, W. O. (2020). Credentialing and privileging: A primer for nurse practitioners. The Journal for Nurse Practitioners, 16(2), 91-95.

Patel, R., & Sharma, S. (2020). Credentialing. In StatPearls [Internet]. StatPearls Publishing.

Reed, S. M. (2020). National Provider Identifier: Why Every Clinical Nurse Specialist Needs One. Clinical Nurse Specialist, 34(5), 231-233.

Rubin, R. (2022). When physicians spread unscientific information about COVID-19. Jama, 327(10), 904-906.