Guide to Provider Credentialing

What is Provider Credentialing?

Provider credentialing is the systematic process of checking and validating the education, skills, training, experience, and professional history of healthcare practitioners who aim to deliver care or services. The process could involve looking at the provider’s past roles, licenses, degrees, certifications, references and many other data-points.

Credentialing is done to verify that the health practitioner is skilled and qualified enough to perform their role. It’s about ensuring that the provider is who they claim to be so that patients can be protected from bad actors, and healthcare orgs can reduce their exposure to risk.

Who is Provider Credentialing For?

Provider credentialing serves everyone involved in the delivery of health or medical services – i.e., the patients, the practitioners, and the payers. The process aims to prevent bad actors from leveraging technology and other means to commit fraud or misrepresent their training, education, and experience; thus, it mitigates the risk of patient harm, malpractice, and legal or compliance liabilities.

Credentialing vs. Privileging

Credentialing is about verifying if the practitioner is adequately qualified and licensed to perform the skills necessary for the position they are hired for; privileging is when you allow them to practice at your specific facility. Generally, credentialing is performed first and privileging for the necessary facilities follows.

Why is Credentialing Important?

Credentialing is important because it safeguards everyone involved in both the delivery and reception of health or medical services.

Patient Safety

Credentialing shields patients by ensuring that they receive care from providers who have the required qualifications, skills and experience for their role and services. In turn, patients benefit by receiving improved care in a safe and secure environment.


Credentialing protects healthcare providers and organizations by ensuring they comply with federal and state regulations. It significantly reduces the risk of bad actors operating within their organizations, thus ensuring patients receive proper care and mitigating liabilities.


Payers (be it private or government-managed care and insurance entities) carry out provider credentialing to approve practitioners before granting them reimbursement. They need up-to-date credentialing data to ensure the providers they pay to provide care for their members are licensed and give expert clinical services.

How Does Provider Credentialing Work?

Both provider organizations (e.g., clinics, hospitals, virtual care, etc.) and payers carry out credentialing, but they manage slightly different processes. Provider organizations initiate the process by gathering the necessary information or data. The payer (be it private sector or government- managed) uses credentialing to assess the providers in their networks.

The credentialing process starts when the provider submits an application enclosing their information, such as education, licenses, work experience, and other data.

Gather Information

The credentialing department or organization acquires information (e.g., data, documents, etc) from multiple sources – including the provider – with the aim of verifying it.

Primary Source Verification (PSV)

Next, the credentialing party engages in PSV of the data and documents it collected earlier to determine their accuracy. The goal is to weed out bad actors that could misrepresent and falsify their qualifications, experience, and work history.

PSV could involve the following (among other steps)

PSV is a crucial step of the credentialing process as it directly deals with the question of reviewing, verifying, and authenticating the provider’s qualifications and competencies. It must be done correctly so as to protect patients and mitigate liability. However, it can be a daunting process as it involves dealing with vast amounts of data from disparate sources.

If done manually, the PSV process may take multiple weeks to complete. However, prudent organizations use software (e.g., Verifiable) with direct API access to these sources to complete verifications in minutes.


Credentialing organizations or professionals don’t make the final decision about provider applicants – this is left to the leaders or committees the provider is working for once they acquire insights from the credentialing process.

Providers are re-credentialed approximately every two years to ensure they stay capable and compliant. During these two years, data has to be collected on the providers so as to inform subsequent re-credentialing efforts, along with monthly monitoring for new sanctions and exclusions.

Provider Credentialing Challenges

An efficient and seamless credentialing process must be wary of systemic or organizational breakdowns, which may highlight deficiencies in an institution’s verification process. These are some of the common challenges organizations face when credentialing:

Inconsistent Credentialing Standards

Absence of standardized procedures or benchmarks can cause organizations to miss critical discrepancies or grant unwarranted approvals.

Inadequate Communication Channels

Gaps in communication, either interdepartmental or with external institutions, can mean essential information about a professional is lost or not transferred, leading to a potentially risky hiring.

Delayed Verification Turnaround

Consistent delays in verification processes without legitimate cause might hint at organisational inefficiencies or a lack of urgency in the process.

Lack of Regular Audits

Not periodically reviewing and auditing the credentialing process might lead to outdated practices or missed red flags.

Poor Record-Keeping

A robust record-keeping system is the backbone of credentialing. If files are disorganized, missing, or not stored with adequate security, it can lead to data breaches or misjudgments during the verification process.


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Provider Credentialing in 2023

The regulatory side of credentialing doesn’t change frequently, but the task of performing it correctly amid increasingly complex realities is getting more challenging.

To overcome these challenges, the most prudent organizations are taking these steps:

Integrating Credentialing to Payer Enrollment

Payer enrollment is when a provider organization (e.g., hospital) applies to become eligible for reimbursement from health plans, like Medicare and Medicaid.

Changes in the medical landscape (e.g., health system closures and mergers) and the need to uncover potential payer obligations/reimbursements is pushing them to integrate provider credentialing with payer enrollment. Payer enrollment requires similar data as credentialing, so it makes sense to re-leverage that internal capacity to access a key revenue source.

Sharing Information Digitally

It’s not efficient or safe to exchange information via paper, hence more organizations are investing in using digital tools to send and receive documents.

Leveraging Automation

Both provider organizations and payers alike are using automation to accelerate and de-risk their respective credentialing processes. 

Tools like Verifiable, for example, equip credentialing teams to rapidly carry out PSV tasks in real-time, perform NCQA and other standards-compliant forms of credentialing, and work through large volumes of applications at a faster rate. Likewise, they use automated tools to monitor for re-credentialing and ongoing compliance.

This doesn’t take human credentialing staff out of the equation; rather, it makes better use of their time and resources. Instead of getting bogged down with manual PSV tasks, they could use automation to review red flags in detail, investigate discrepancies, and other functions to drive more value for everyone involved, be it the patient, practitioner, or payer. 

The Key to Efficient and Risk-Free Provider Credentialing 

Ultimately, today’s provider credentialing process involves significant – potentially thousands in some cases – of data points to review and verify. It’s unrealistic to carry these checks out manually, be it for accuracy, timeliness, or preventing risk and liability. Moreover, the people involved in the process can use their expertise in far more valuable ways than to engage in manual PSV or other review work that is better left to automation.

Frequently Asked Questions (FAQ)

What are some common credentialing red flags among applicants?

Lost privileges

Losing privileges from a previous institution may indicate serious performance or ethical misconduct.

Frequent relocations

In today’s healthcare ecosystem, moving from practice to practice is easier and more accepted. However, it is still good to ask for its cause. The same is true for brief employment periods at several hospitals.

Unexplained gaps in work history

Same as above, this used to be an automatic red flag. But seeing employed physicians moving from practice to practice with significant gaps in between is a red flag. Significant unexplained gaps may mean that they are concealing issues or problematic events during this period.

Training program interruptions

This might indicate professional or academic difficulties.

Changes in staff role/classification

frequent or drastic changes in a professional’s status or position in an institution could hint at performance-related challenges or interpersonal relationship issues

Lack of or negative feedback from reference

Failing to get feedback from a reference or garnering negative remarks may suggest strained professional relationships or issues with their past employment. An applicant’s unwillingness to provide detailed references or to allow contact with their past employer should raise concerns.

Fraud allegations

Any instances of fraud claims or investigations into fraudulent activity are immediate red flags, indicating serious ethical breaches.

Frequent malpractice claims or legal disputes

While occasional complaints can be a part of a professional’s career, many malpractice assertions suggest a recurring pattern of inferior quality or care or substandard clinical judgment. The same is true if the practitioner has a record of prior investigations by the state licensing board or other healthcare organizations