Are credentialing and privileging the same?
No. Credentialing evaluates qualifications; privileging authorizes specific patient care services based on credentials and performance.
Credentialing vs privileging vs payer enrollment
Credentialing checks a clinician’s qualifications, privileging authorizes specific patient care services, and payer enrollment applies for inclusion in insurance panels so the clinician can bill and be paid. These are separate processes for physicians, NPs and PAs starting a job, not interchangeable steps.
Three separate processes
Credentialing means obtaining, verifying and assessing a clinician’s qualifications to provide care in or for a health organization. Privileging is the organization’s authorization of the scope and content of patient care services, based on credentials and performance. Payer enrollment is the application to health insurance plans and networks for a place on their provider panels so the clinician can bill and be paid.
Credentialing and privileging take place at initial appointment and again at reappointment or renewal. Quality is evaluated on an ongoing basis between those events.
What is commonly verified
- Education and postgraduate education; board certification and continuing medical education.
- Licensure; state sanctions and federal OIG sanctions; DEA or controlled substance registration.
- Identity and criminal background checks.
- Liability insurance and claims history; malpractice claims history; an NPDB query.
- Work history, medical staff history and clinical privilege history.
- Peer and professional references.
How a hospital review moves forward
- Medical staff services verifies the information.
- The department chair reviews it.
- The credentials committee reviews it.
- The medical executive committee reviews it.
- The governing body makes the decision.
- An appointment letter follows.
Assumptions to question
The AMA presentation identifies common misconceptions: that the process starts when a position is accepted, that the offer-letter start date is the first patient day, and that an HR application serves credentialing, privileging and enrollment. It also cautions against treating employment and peer references as the same or assuming you are not responsible for incorrect information submitted on your behalf.
Documentation that can hold up review
Common challenges include incomplete records, overlooked releases and missing copies of a license, board certification or diploma. Specialized privileges may need extra documentation, while work-history and peer-reference responses can be slow.
Frequently asked questions
Does an offer-letter start date mean I can see patients that day?
Do not assume it does. The AMA identifies that assumption as a misconception; ask when the separate review processes begin and what the realistic first patient day is.
Who decides hospital appointment?
After verification and reviews by the department chair, credentials committee and medical executive committee, the governing body decides, followed by an appointment letter.
Should I check information submitted for me?
Yes. Do not assume you are free of responsibility for incorrect information someone submits on your behalf. Verify it yourself.
Sources
General information, not legal, tax or insurance advice. Confirm details with the source and with your state board, employer or insurer.