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Hospital and Insurance Credentialing. Pat Borman, MD Practice Management Didactics. WHO CREDENTIALS. HOSPITALS HEALTH INSURANCE COMPANIES HEALTH DELIVERY SYSTEMS HMO’s. WHY CREDENTIALING.

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Hospital and insurance credentialing

Hospital and Insurance Credentialing

Pat Borman, MD

Practice Management Didactics


Who credentials
WHO CREDENTIALS

  • HOSPITALS

  • HEALTH INSURANCE COMPANIES

  • HEALTH DELIVERY SYSTEMS HMO’s


Why credentialing
WHY CREDENTIALING

  • Hospitals and Health Insurance Companies and Health Care Delivery Systems have a legal and ethical responsibility to the public and insureds to insure that physicians are adequately trained to practice quality medicine with reasonable skill and safety.


Hospital credentialing the process
Hospital Credentialing:The Process

  • Request application and complete it

    • If anything is missing this causes delays

    • Be neat, accurate, complete, professional

    • Passport size photos

    • Include the check for required amount

      • Currently at Swedish $350 complete in 3-6 months or $850 complete in 30-45 days


Hospital the credentialing process
Hospital:The Credentialing Process

  • Completing the Application

    • Request ALL the privileges you qualify for and supply documentation

    • Never request privileges you do not qualify for

    • Letters of Recommendation: Program Director and others

    • Releases Criminal Background Check and National Practitioner Data Bank


Verification
VERIFICATION

  • Each entry in your completed application is verified at the source

  • Now your application is complete and confirmed as true and accurate

  • File is forwarded into committees for recommendation.


Recommendations
RECOMMENDATIONS

  • Chief of Family Practice reviews your file and makes a recommendation for appointment to the Credentials Committee

  • In some hospitals each department you work in must sign off: OB/GYN, PEDS, SURGERY, MED before the Credentials Committee reviews your file


Recommendations1
RECOMMENDATIONS

  • The Credentials Committee reviews everything again and passes a recommendation to the Executive Committee.

  • The Executive Committee will make a recommendation to the Board of Directors of the Hospital


Final determinations
Final Determinations

  • The Board of Directors of the Hospital has FINAL AUTHORITY in privileging:

  • Grant

  • Deny

  • Modify

  • Revoke


Insurance and hmo credentialing
Insurance and HMO Credentialing

  • Application is similar

  • Verification Process is the same

  • Tend to be fewer layers of Committees to seek approval


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