Hospital Credentialing: What to Expect as a Physician

It doesn’t matter whether you work in private practice or work for a hospital group. Almost every physician has to go through credentialing and privileging at some point in their career. These two terms are used interchangeably in the medical community, but do you know what they mean? Do you know what they’re for or what it takes to get approval? Hospital Credentialing Expectations and privileging take place after you’ve received licensure. Without your medical license, you will not be able to get credentialed or obtain privileges. Keep reading to learn all about hospital credentialing and what to expect as a physician.

Credentialing and Privileging: What Are They?

Credentialing and privileging are crucial to physicians in every specialty. From primary care physicians to cardiologists, almost every doctor will need both. But what’s the difference between the two?

Credentialing

Credentialing is the process that verifies a physician’s credentials. It is a way to confirm that the physician graduated from medical school and received their certification. Credentialing also ensures that a physician has a license to practice medicine in their specialty and their state. Ultimately, it is a way to ensure patient safety. How? Because it prevents hospitals and practices from hiring just anyone. You cannot pretend to be a physician and get hired to practice medicine. The credentialing process makes that impossible. Credentialing is the first step in gaining employment as a physician. It is also a prerequisite for obtaining privileges. Physicians must go through the process of credentialing before they can apply for hospital privileges.

Privileging

Privileging, on the other hand, is a slightly different process with a very different purpose. This process centers on the physician’s scope of practice explicitly related to patient care. Depending on the type of patient care you provide, you may need different kinds of privileges. Some physicians may qualify for all, for some, or none at all. There are three main types of privileges:

• Admitting privileges
• Courtesy privileges
• Surgical privileges

What Are Admitting Privileges?

Admitting privileges allow primary care physicians the ability to admit a patient in their care into a hospital. Sometimes referred to as “active privileges,” this type of privilege allows a doctor to work as a member of a hospital’s medical staff on occasion. With admitting privileges, physicians can admit their patients directly to the hospital without going to the ER first. Instead, the physician usually only needs to make a phone call and fill out a few forms for their patient to get admitted into the hospital. However, with the creation of the hospitalist role, admitting privileges for primary care physicians are on the decline. Hospitalists must admit patients with the most significant medical needs first. They make the ultimate determination of who gets admitted and in what order. Having admitting privileges does not mean that your patients will get any preferential treatment. Privileges alone will not get them admitted ahead of patients with more immediate medical concerns.

What Are Courtesy Privileges?

Courtesy privileges work very differently. These allow physicians to admit patients on occasion or visit admitted patients regarding their general medical care. If one of your patients gets admitted into a hospital, courtesy privileges allow you to visit that patient but not treat them. Courtesy privileges show that you have an association with the hospital. They do not mean that you can treat patients on the premises.

What Are Surgical Privileges?

If you’re a surgeon, you’ll want to secure your surgical privileges. Physicians with surgical privileges can perform outpatient surgeries and use the hospital’s operating room. Surgical privileges aren’t limited to hospitals. They are also required to work in surgical centers and a host of other medical facilities.

Do Credentialing and Privileging Go Hand in Hand?

The answer is yes, and no. You can get credentialed without having privileges. But you cannot obtain privileges without going through the credentialing process first. All physicians need credentialing to practice. Privileges, on the other hand, permit physicians to treat and perform specific procedures on patients. Without those privileges, physicians cannot provide any in-hospital services to patients.

Why is Credentialing So Important?

Credentialing is the healthcare industry’s best way to protect patients. It is a way to ensure that patients receive high-quality care from physicians who have met state licensure and certification requirements. But what about physicians that own their practice? Do you need to be credentialed if you don’t work for a hospital or another doctor’s practice? If you want to accept health insurance from patients, the answer is yes. Insurance companies will not pay claims unless the physician is already credentialed. Like hospitals and large healthcare groups, insurance companies use credentialing. It is another way for insurance companies to make sure that they are paying legitimate, licensed physicians. Credentialing is a requirement if you wish to bill through Medicare and Medicaid. Through credentialing, health groups verify that you have completed your medical training. They do this by looking at your diplomas, licenses, and certifications. They also look to see if you have any pending medical violations. Physicians will have to undergo credentialing many times throughout their careers. It is common for hospitals and healthcare organizations to re-credential every two years. Keep in mind, credentialing isn’t just for physicians working in hospitals. Almost every healthcare facility, urgent care clinic, and long-term care facility requires credentialing. There are a variety of third-party agencies and services that handle physician credentialing. However, members of the hospital staff themselves do not do it.

Why is Privileging So Important?

Privileging ensures that a physician has experience and competency in their specialty or area of medicine. Without privileges, you cannot treat patients in a hospital setting. Various members of your hospital’s medical staff, sometimes called an Executive Committee or Credentials Committee, would decide if you qualify for privileges. And that’s because the hospital has to answer to accreditation bodies like The Joint Commission or The National Committee for Quality Assurance. The Joint Commission is a not-for-profit agency that defines the standard for patient care and hospital practices. It requires hospitals to grant privileges to any physician who wants to treat patients in that particular hospital. Privileging is a requirement of Medicare, Medicaid, and most state governments. For Medicare and Medicaid patients to seek treatment at a hospital, it must have accreditation with the Joint Commission. And the way to maintain accreditation is to ensure that physicians have privileges to practice there. Like credentialing, physicians will have to go through the privileging process multiple times. New physicians will quickly learn that this is something you’ll need to do every few years. The Joint Commission requires that physician privileges be renewed every two years (three years in the state of Illinois). Hospitals and healthcare organizations always have the prerogative to deny or limit privileges. The medical staff bylaws of your hospital will stipulate the timeframe in which your application will be approved or denied. If you don’t qualify for privileges at one hospital, you may still be eligible for them at a different hospital. As an independent physician in private practice, you may decide to seek privileges at one hospital or several. However, if you are an employee of a specific hospital, you will only need to seek privileges for that particular location.