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Credentialing in the medical field is a way to ensure that people who work with patients, like nurses and doctors, have the right education, certifications, and professional experience. In addition, the medical industry must uphold rigorous safety standards. Finally, without proper medical credentialing, businesses may face financial difficulties when getting paid by insurance companies like Medicaid and Medicare for their services.

Using any healthcare software solution without physician accreditation can be incredibly challenging. For a medical practice or healthcare provider to succeed in this market, it must have the right credentials.

According to a statement made by Healthcare Innovation, “Medical credentialing is increasingly vital since it is the only process that enables people to firmly invest their trust in the healthcare professionals of their choice.

Medical credentialing is important for healthcare businesses because it lets patients check that their doctors and nurses have the right education and experience to treat them.

In 1000 B.C., the Cult of Zoroaster required physicians to treat three heretics, which marked the beginning of medical credentialing. According to Continuum, if all three survived, the doctor would be qualified to care for patients until the end of their profession. Since ancient Persia, the process for accrediting doctors has changed a lot, but the basic idea is still the same: to ensure that doctors are qualified to treat patients.

By the end of the article, the reader will gain a thorough understanding of medical credentialing, how it works, and comprehend its significance, structure, challenges, and ways that it can improve in healthcare institutions.

Importance of Medical Credentialing

1. Gives Patients a Sense of Self-Assurance

The way your patients feel has a significant impact on how quickly they heal. Patients who have faith in their doctors may feel more confident in following their advice, whether it involves changing their diet and exercise routines, trying a new medication, or getting treatment. So, naturally, patients who have faith in their medical professionals are more likely to stick with the clinic and won’t go elsewhere for a more qualified doctor.

In the same way, having doctors and nurses with full medical credentials will help your company hire more people, such as support staff, new physicians, physician assistants, licensed vocational nurses, registered nurses, and nurse practitioners. Everyone in the medical field wants the respect that comes with working alongside those who are also well-trained and up-to-date on the newest industry developments. By emphasizing the team’s excellent skills, you inspire future excellence.

2. Demonstrates Professionalism

When working in the medical field, it is always best to keep detailed records, so there is no doubt about your skills. It is a modest thing to pay to be able to reassure patients of your credentials by filling out the paperwork needed to do so.

According to Healthcare Innovation, “patients are assured of their healthcare professional’s merit and expertise through a systematic procedure encompassing data collection, primary source verification, and committee assessment by health plans, hospitals, and other healthcare agencies.”

Since there would be so much documentation, medical professionals may have previously shied away from the credentialing procedure. But thanks to current techniques, much of this information may be handled online. So before beginning a deal with another company or any hospital permitting you to become an affiliate, be sure your team can use electronic credentialing for any institutions that want to check your standing.

4. Reduces Medical Errors

Healthcare workers should have valid medical qualifications to improve the safety and security of the whole field.

According to a report by Healthcare Innovation, medical mistakes kill 98,000 people in the United States every year. This shows how important medical credentials are. Also, patients have the right to think that their doctors and nurses are competent and acting legally and morally.

5. Assures Adequate Staffing

Medical credentialing is crucial to building your team if you’ve struggled to maintain the necessary personnel levels to serve your local community.

To help them with credentialing, new medical staff candidates who are not coming through a job placement agency should begin the process as soon as possible. The completion time is up to four months. Make materials, such as a credentialing packet, to be given to all new hires to help smooth the road. In addition, it will assist them with their application.

If you want to ensure that new employee onboarding goes smoothly, your HR department should keep track of all applicants’ progress toward obtaining medical credentials.

Medical Credentialing Structure

  • No one should be allowed to work in healthcare before they have the proper credentials. Instead of leaving healthcare personnel hanging for months, the facility should quickly complete the initial credentialing. Finally, credentials must be approved by the board of directors.
  • Many organizations can check credentials today. In addition, some healthcare facilities may work with them to speed up the process, especially if the healthcare worker is from outside the U.S. or needs workers quickly.
  • Healthcare facilities should regularly check their credentialing processes to ensure they are updated with any new federal or state rules. Legal counsel should also assess any modifications to the credentialing process before they are implemented. The regulating body typically gives the ultimate approval.
  • Internal administrative redress must be available for candidates with dubious credentials.
  • It is recommended that providers have their privileges reviewed every two years after they have been accredited. This is crucial because the provider might have picked up new abilities they could apply. For instance, a provider might want to start a hospital program after taking a bariatric surgery course. On the other side, some healthcare professionals can be aging and more prone to errors, so privileges for these surgeons should be restricted to only a few surgeries. Other healthcare professionals may have developed a condition like Parkinson’s disease or seizures that makes it unsafe for them to operate on patients, necessitating the restriction of their privileges.
  • Bylaws that specify a procedure for considering and approving applications should be in place at the facility. The governing body should record the credentialing process and support any final decisions.
  • The Americans with Disabilities Act must be followed by all employers. The fact that the applicant has a disability cannot justify discrimination or the denial of credentials.


Medical Credentialing Constraints

Errors can occur during any procedure. However, credential errors may ultimately result in losing a person’s license or a company’s reputation. As you know, missing credentials or compromised privacy carries much weight in the healthcare industry. In addition to enrollment problems, a poorly managed credentialing system may result in legal and financial difficulties.

The most frequent issues with the medical credentialing process are listed below, along with a straightforward IMS Global framework that might solve most, if not all, of those issues.

Obtaining Current Information

Healthcare businesses need help accessing application information. Almost 85% of credentialing applications contain incomplete, outdated, or erroneous information. For example, if a candidate’s contact information (including email and phone number) changes, it must be re-attested in the CAQH database for the application to be processed.

Getting a medical license can slow down quickly if paperwork, training records, or information needs to be included or corrected. Since many healthcare professionals frequently switch between several facilities, this problem becomes more pervasive and requires businesses to adapt to the changes.

Following deadlines

When it comes to your healthcare organization’s revenue cycle, medical credentialing might be a significant obstacle. An organization may need up to 90 days to process the application evaluation. The processes can take up to six months, and additional players, such as insurance firms or contract negotiators, further delay your business.

Fulfilling State Regulations and Standards

Each state establishes the requirements for provider credentials and medical service policies’ rules. Additionally, several national organizations like CAQH have their own set of rules. This causes problems with the medical credentialing process because the criteria differ not just from state to state but also due to shifting legislation or policy. Any credentialing system must adapt to new rules as they emerge and take them into account immediately.

Maintaining Confidentiality and Safety

A crucial part of credentialing is background checks. Background checks ensure that the candidate meets the qualifications and national licensing standards, such as having a degree or having worked in the field before. Maintaining confidentiality and safeguarding data is essential at this process stage and in the future. 

The credentialing organization and insurance companies must know the practitioner’s history of malpractice, board proceedings, or reports to the National Practitioner Database. Failure to disclose incidents, system backlogs, or a lack of real-time data can all lead to rejection or, worse yet, legal repercussions for the applicant or the person issuing the credential. For this information to be safe and up-to-date, your credentialing platform needs to be able to connect to many databases.

Methods for Improving the Medical Credentialing Process

Medical staff services professionals are frequently at the forefront of patient well-being; nonetheless, their jobs often require them to navigate a path fraught with inefficiencies and obstacles.

Listed below are five actions that can be taken to help enhance the process of obtaining credentials.

Implement a standardized approach

Getting credentials is a confusing process mainly done on an as-needed basis. Credentialing departments may delay some activities to put out fires elsewhere, then need to catch up on what they were working on. Nevertheless, Healthcare organizations require credentials as soon as possible.

According to Marshall Baker, who serves as an educator with the Accreditation Association for Ambulatory Health Care and works as a business consultant for physicians, standardization is essential. Getting everyone on the same page and lowering the possibility of error can be accomplished by standardizing the credentialing procedure for the professional staff and other providers.

Adapt to Modern Technology

Several medical staff services agencies still use paper files to manage licenses and certifications. But according to Baker, the paper systems need to be updated and pose a risk to the system. In addition, he says that changes in technology have made it easy to gather and store the information needed for credentialing.

Baker advises automating procedures and record keeping and setting up alerts for when licenses and certificates are about to expire. He also suggests creating simple-to-use checklists for various professions or divisions.

Concentrate on Your Initiative

Jill Schwieters, the President of Cielo Healthcare, says that systems with many locations often make things hard by requiring a different medical staff application for each facility where the provider would work. However, credentialing procedures can cover the same area by requesting the same data or consulting the same sources multiple times.

Some of these problems can be mitigated by technology, but Schwieters notes that internal adjustments may require more work. Nevertheless, a centralized solution that only requires one application can save time and work, even if some privileges still need board or CMO approval.

Even though it will take a lot of time to change decades of practice, negotiate with physician leadership, adapt governance, and change bylaws, she claims it will be more time-effective in the long run.

Stay updated

According to experts, employees in the divisions responsible for medical staff services and credentialing should look for ways to maintain their expertise. For example, participating in professional organizations like the National Association of Medical Staff Services (NAMSS), making connections with colleagues, and reading updates from groups like the Center for Affordable Quality Healthcare (CAQH) will help them keep up with industry best practices.

By keeping up with the latest rulings, policies, and approaches to medical credentialing, the healthcare sector can provide smooth services to its patients. Choosing the right physician credentialing service tailored to your specific needs and requirements will eliminate any hassle while delivering the best possible treatment to patients.


  1. O’Connor, S. (2021, February 4). What Is Medical Credentialing, and Why Is it Important? Retrieved from
  2. Patel, R., & Sharma, S. (2022, October 24). Credentialing – StatPearls – NCBI Bookshelf. Retrieved from,history%20of%20a%20healthcare%20provider.
  3. Barajas. (2016, December 27). 5 Ways to Improve the Credentialing Process. Retrieved from
  4. 5 Challenges in the Healthcare Credentialing System | TAO. (2020, February 24). Retrieved December 27, 2022, from





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