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Credentialing & Privileging Issues

Credentialing Claims in Arkansas

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.

credentialing requirements

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.

If you are denied privileges because of something in your background, whether it be medical malpractice, professional license discipline, criminal convictions, questionable medical education/training, or allegations that you did not fully disclose all pertinent issues or answer questions in the application correctly, you need an attorney experienced in this area of the law, like Mr. O’Quinn, to represent you. Moreover, if you are subject to an improper credentialing and privileging process, you should seek legal assistance from an attorney qualified in these matters.

You have the right to be represented by an attorney throughout credentials/privileges processes and you should seek competent representation if you expect to encounter problems. Your rights, called “due process rights,” are often primarily determined by the medical staff by-laws at your hospital or a third-party payor's practitioner credentialing standards. You can be certain that an attorney is advising the hospital or third-party payor, so you too should have good legal representation. You should immediately contact Mr. O’Quinn for assistance when you learn that there are problems with your credentialing or privileging processes.
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