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Hospital and Insurance Credentialing

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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  1. Hospital and Insurance Credentialing Pat Borman, MD Practice Management Didactics

  2. WHO CREDENTIALS • HOSPITALS • HEALTH INSURANCE COMPANIES • HEALTH DELIVERY SYSTEMS HMO’s

  3. 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.

  4. 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

  5. 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

  6. 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.

  7. 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

  8. 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

  9. Final Determinations • The Board of Directors of the Hospital has FINAL AUTHORITY in privileging: • Grant • Deny • Modify • Revoke

  10. 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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