Why Is Medical Credentialing So Important?
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Medical credentialing is a critical process that ensures the legality and competence of a healthcare provider. The credential verification process takes place when a healthcare provider applies for a job in a healthcare organization. It's the responsibility of that organization to verify the credentials and licenses of the applicant to ensure that they don't violate any state laws and are able to practice efficiently and fairly.
Here are three reasons why medical credentialing is so important.
Prevents Revenue Loss of Healthcare Organizations
Credentialing the staff at a healthcare organization ensures compliance with federal and state regulations. That's because when an organization claims reimbursement from an insurance company or a government program like Medicaid or Medicare for the services offered by a physician, nurse, or pharmacist, the payer can negate reimbursement.
If the reimbursement is already done, the healthcare organization can get a hefty fine, civil monetary penalties and may even be required to pay the full reimbursement amount.
Therefore, it's the responsibility of the organization to perform healthcare providers credentialing upon hire and continue it through an ongoing process. In case a provider's name is present in the (LEIE) List of Excluded Individuals and Entities by the (OIG) Office of Inspector General, and the provider hasn't been credentialed for the past 2.5 years, the healthcare organization will be at risk of a massive financial hit.
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Protects The Patients
Please note that the LEIE is only a single data point against which a provider must be credentialed. Other primary sources include OFAC, FACIS®, National Abuse Registry, Social Security Death Master File, and Sex Offender Registries, at minimum.
A healthcare provider can also be stopped from practicing due to unassociated things like nonpayment of student loans or not renewing their license.
Combining primary-source data brings transparency to providers who are in direct contact with patients.
The Joint Commission has credentialing standards to certify and accredits over 22,000 healthcare programs and organizations throughout the US. They require (FPPE) Focused Professional Practice Evaluation while credentialing and (OPPE) Ongoing Professional Practice Evaluation while assessing the provider's practice period.
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Safeguards Healthcare Organizations from Charges
Although medical credentialing is crucial to comply with the best practices, some conditions may not control healthcare administrators and providers.
When an organization faces a lawsuit, the justice system will consider if the organization complies with the government's requirements, the quality standards through accreditations and certifications, and the best practices that are on par with the regulatory requirements.
On the contrary, if an organization faces a lawsuit for negligence or patient endangerment, and the provider is named under the national abuse registry or uses a deceased person's NPI number to prescribe medication illegally, that organization will lose the lawsuit and face reputational loss.
Medical Credentialing Services is Important
At Premier Medical Credentialing, we offer medical provider credentialing, healthcare provider credentialing, Medicaid and Medicare enrollment services, and more. Check out our services and get in touch with us for pricing and free consultation.