Simply stated, ‘credentialing’ is the process of evaluating the qualifications and practice history of a medical provider. Physicians and healthcare providers have been undergoing a credentialing process dating back to 1000 BC in Persia.
Our processes have become more refined as time has progressed, but it wasn’t until around 1990 that national organizations dedicated to the credentialing of medical providers began to exist. The most notable of these being NCQA, or the National Committee for Quality Assurance. NCQA sets a variety of standards that act as a guideline for how to credential medical providers. Some of the guidelines include using primary source verification (the process of checking/verifying from the original source of a specific credential) to check board certification, education, training, malpractice claims, and other factors that can have an impact on patient care.
There are many organizations that do primary source verifications for credentialing, and it can be overwhelming to try to tread your way into the world of credentialing without any prior experience. To help clarify, here are some of the major players when it comes to credentialing physicians, nurse practitioners, and physician assistants:
National Practitioner Data Bank: The NPDB acts as a nation-wide program to check for medical malpractice claims, complaints, license suspensions/revocations, or other issues.
American Board of Medical Specialties: ABMS acts as a way to verify that physicians are Board Certified. Board Certification is a voluntary process that implies a physician has exceptional expertise in a particular specialty or subspecialty of medical practice (Internal Medicine, Surgery, Dermatology, etc.) that has been verified by a board of representative providers in the specialty field.
Student Clearing House: The National Student Clearinghouse acts as primary source verification for education history.
Sanctions and Exclusions: The Office of Inspector General (OIG) and the System for Award Management (SAM) are two entities that serve to verify if healthcare providers have any sanctions against their license or exclusions that would affect their ability to practice medicine.
State License Verification Websites: Each State Medical Board runs their own license verification program. These are further separated between nursing and physicians/physician assistants.
Why are these things important? Having a series of guidelines in place ensure that patients are receiving the highest level of care from healthcare professionals who have undergone the most stringent scrutiny regarding their ability to practice medicine. As a patient, you can be assured that your health is in good hands when your providers have gone through these credentialing processes. As a provider, you have the knowledge that your colleagues are being held to the same standards as yourself, and that a potential employer values quality care for its patients.
This is simply a crash-course overview on credentialing that is specific to the licensing of medical providers, but hopefully leaves you with a better understanding of what credentialing is, and why it is important to your health.