Credentialing vs. Privileging: Understanding the Basics and Establishing Processes

In today's healthcare landscape, ensuring that your medical professionals are properly qualified and authorized to provide specific patient care services is a critical responsibility. This process involves two primary components: credentialing and privileging. Understanding the distinction between the two and how to execute each function will empower your organization to ensure competent providers deliver next-level patient care.

Credentialing vs. Privileging - Understanding the Basics

Credentialing is evaluating and confirming various qualifications of healthcare practitioners, such as licensure, education, training, and certifications. It is the foundation for assessing a practitioner's eligibility to provide medical services within a healthcare organization.

Privileging, however, involves authorizing a healthcare practitioner to perform specific clinical activities or procedures within their scope of practice. Unlike credentialing, which focuses on qualifications, privileging determines the specific patient care services a practitioner can deliver.

Establishing a Rigorous Credentialing and Privileging Process

Implementing a fair credentialing and privileging process promotes patient safety, regulatory compliance, risk management, quality standards, and good institutional governance. A thorough process includes the following seven steps:

1. Establish Policies and Procedures: Create clear policies and procedures that outline the credentialing and privileging processes. 
2. Create Privilege Delineations: Define your organization's clinical activities and create privilege delineations or forms accordingly.
3. Develop Application and Required Documents: Design an application process and compile a list of required documents, such as proof of education, training, and work history. 
4. Establish Verification Processes: Set up processes to verify credentials for initial credentialing and re-credentialing every two to three years, including verification of licensure, DEA and CDS, education, training, certifications, work history, and malpractice history.
5. Define Decision-Making Process: Determine the decision-making process involving physicians and representatives from the board or management team.
6. Monitor Expirables: Implement ongoing monitoring of expirables such as licenses and certifications to ensure compliance between credentialing events. 
7. Implement Automation: Consider utilizing credentialing and privileging software, like CredentialStream ®, for automation to streamline the process and ensure efficiency.

Automate Credentialing and Privileging with CredentialStream

Both credentialing and privileging are painstaking processes that require diligence and attention to detail to be executed properly. If your organization relies on manual processes and disjointed point solutions, you may encounter inefficiencies, errors, and delays that jeopardize patient safety and your bottom line.

CredentialStream®, by HealthStream® provides a comprehensive and easy-to-engage platform for accessing provider qualifications. It delivers everything needed to request, gather, and validate provider information.

Five core modules enable you to serve the entire provider competency lifecycle:

Enroll: Automate the provider enrollment process and speed up the revenue cycle

• Library of 7,000+ payer forms
• Payer data management
• Roster reports for delegated entities 

Onboard: Streamline and automate onboarding tasks

• Providers and stakeholders view and complete tasks online
• Onboarding workflows with pre-built integrations for human resource and payroll

Privilege: Automate the clinical competency lifecycle

• Privilege request and conditions management
• Privilege and appointment workflow
• Track and analyze provider-specific procedure volumes

Evaluate: Comprehensive assessment of a provider’s clinical performance

• Measure procedure counts and annual minimums
• Library of procedure codes and performance indicators
• Identification of low-volume and non-granted scenarios

Network: Consolidate your provider data management activities within a health plan

• Drill down into provider status, participation, and due dates
• Support inbound and outbound rosters for delegated entities
• Manage provider directories and outbound reporting with CMS requirements

Addressing the challenges associated with credentialing and privileging requires healthcare organizations to adopt innovative solutions that facilitate processes, enhance communication, and ensure compliance. With its array of features, including paperless applications, automated data validation, content libraries and more, CredentialStream empowers organizations to enhance patient safety, streamline operations, and meet regulatory requirements effectively.

Learn more about CredentialStream and how it can help your team thrive.