Hospital and insurance credentialing
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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

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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

  • 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

  • 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

  • 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

  • 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

  • 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


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

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

  • Grant

  • Deny

  • Modify

  • Revoke


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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