Licensure, credentialing, and privileging

Published on 07/02/2015 by admin

Filed under Anesthesiology

Last modified 07/02/2015

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Licensure, credentialing, and privileging

R. Scott Gorman, MD and Carol B. Garrison, CPMSM

Health care organizations—such as hospitals, health plans, and provider networks—must be certain that individuals who provide health care services for their respective organizations are fully qualified, competent, and able to perform those services. This process includes not only evaluating an applicant’s licensure and reviewing credentials, but also granting specific privileges to that provider. The determination of both provider qualifications and competency is essential if a health care organization is to provide safe competent care while avoiding lawsuits, bad publicity, and financial loss.

Licensure is the process whereby a government board or agency reviews a provider’s education, training, background, and any ethical concerns and, if the standards are adequately met, thereafter grants the provider the right to provide health care services within its jurisdiction. The government views licensure as its primary mechanism of protecting the public from substandard care. The requirements for licensure vary from state to state and sometimes include specific education requirements. Additionally, some states require supplemental competency testing if the provider is several years past formal medical training, received his or her medical training outside the United States, or is not board certified.

Credentialing is the process of assessing and verifying the qualifications of a health care provider to obtain appointment to a medical staff or to be approved as a provider in a health plan or health care network. Although many of the requirements for credentialing are similar to those for licensure, each health care organization determines its own criteria and processes. The health care organization may therefore set standards and expectations for quality, safety, and other performance measures that go beyond licensure standards.

Privileging is the process of evaluating the training, experience, and current competency of an individual to perform specific medical services as a part of a medical staff. Privileges are detailed and specific, and providers may only offer medical services in those areas in which they hold privileges. For most requested privileges, the designated individuals within the health care organization will review the provider’s education and training, past clinical performance, malpractice history, and the number of cases performed. An organization’s decision to limit a provider’s privileges can be grounds for legal action by the applicant or require the organization to submit a report to the applicable state or federal regulatory agency and, therefore, must be done with great care and consistency. Today, most health care organizations also employ a process of ongoing concurrent review after the granting of privileges to ensure that competency is maintained.

How health care organizations credential and privilege providers

The specific processes for credentialing and privileging are delineated in a combination of the health care organization’s medical staff bylaws, rules and regulations, and policies and procedures. For legal and regulatory reasons, it is essential that the processes are clearly outlined and precisely followed. Otherwise, the health care organization may have a limited ability to correct or dismiss providers due to inadequate performance.

In most health care organizations, the data collection involved with credentialing and privileging is performed by individuals specifically designated by the organization. These individuals may function solely as credentialing/privileging personnel, or this function may be part of the broader services provided by medical staff services. Following the collection of data, a credentialing or personnel committee or designee reviews the data and makes recommendations to the governing body. In acute care hospitals, the medical executive committee is responsible for forwarding recommendations to the governing body of the health care organization, which is ultimately responsible for the decisions concerning staff membership and clinical privileges.

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