Hospital and Third-Party Payor Credentialing and Privileging Issues
Credentialing is the process by which hospitals and third-party payor networks, including Medicare, Medicaid, Blue Cross, and other reimbursement and payment programs, evaluate and verify the qualifications of physicians and other licensed healthcare providers to ensure practitioners possess the necessary qualifications. Typically, hospitals and third-party payors evaluate a practitioner’s proficiency through the collection, verification, and evaluation of data relevant to their professional performance. Mr. O’Quinn frequently represents doctors, pharmacists, nurses, and other practitioners in this complex area of the law.
Although the law mandates minimum credentialing requirements, hospitals and third-party payors are often free to expand upon those requirements. To conduct their evaluations, hospitals and third-party payors appoint committees to verify the practitioner’s credentials such as medical training, licensure, and history of discipline or professional misconduct. Credentialing is often an ongoing process, known as periodic credentialing (i.e. re-credentialing), which allows hospitals and third-party payors to reassess a practitioner’s competency. Credentialing and privileging requirements should be detailed in a hospital’s medical staff by-laws and a third-party payor’s practitioner credentialing standards. At times, however, the credentialing and privileging processes often succumb to political battles at the hospital or third-party payor market and economic pressures. As a result, the processes can be used for improper purposes, such as retaliating against practitioners or dismissing them from the network.