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.
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.