Physicians in general often undergo credentialing by the medical institutions and managed care organizations they want to work for and be affiliated with. Such organizations include hospitals, health maintenance organizations (HMOs), and preferred provider organizations (PPOs) which are responsible in providing quality services to their subscribers (Sobelman, 2001). According to Freed et al (2006, p. 913) “credentialing is a systematic approach to the collection, review, and verification of a practitioner’s professional qualification”.
A practitioner’s qualification can be assessed based on his or her professional license, certification, educational background and preparation, clinical experience and professional activity and practices (Jones, nd).
Credentialing therefore is important in evaluating and assessing the competence of medical practitioners. It is important to both the physicians and medical institutions because credentialing serves as the basis of maintaining quality health care and patient safety (Norcal, 1999, p. 1).
Basically, credentialing is a necessity for almost every healthcare providers particularly the physicians for they are directly responsible for the patients’ treatment outcomes. Credentialing is an ongoing process (Rozovsky et al, 1994) that involves review and verification of the physician’s current professional license, current, education, training, hospital privileges and levels of liability insurance as well as review of the physician’s office if applicable to determine the quality of service the physician provide to his own clients (Sobelman, 2001).
It is an ongoing and continuous process because of the need to ensure that the training and practices of the physicians are aligned with the changing needs of the patients. The processes involved in credentialing are necessary particularly the validation of certificates, training and current hospital privileges as well as the Drug Enforcement Administration and Controlled Drug Substance Certificates because these are very important in avoiding any possible risk and professional liabilities in which the managed care organizations can be held liable.
Certificates in particular assured the public that the physician has successfully completed an accredited educational programs, examinations and evaluations, and provide assurance that the physician possess the skills, expertise, knowledge and experience required in practicing his profession (Hillemeier, 2004) When the physician’s capability, scope of practice and specializations are known, risks and liabilities are avoided and managed.
From this, it can be viewed that managed care organizations conduct credentialing of physicians as part of their risk management activities. Defining, risk management, “ it is a planned and systematic process of reducing and/or eliminating the probability that losses will occur” (Yale New Haven Hospital, n. d). It is very common that when patients has complaints regarding the quality of care given to them, the hospital or HMO lose patients or subscribers that could have provided them better profitability.
Complaints from patients and subscribers also pose threat as it can decrease the level of trust patients and the public have for the organization. Thus, managed care organizations see to it that the physicians who will work for them have undergone credentialing which must be designed to aid organizations in choosing competent physicians that has the capability of providing quality care for their patients. Organizations are aware that competent physicians are an important asset to the organization.
On the part of the physicians themselves, credentialing broadens the scope of their practice. The more the credentials a physician holds, the more clinical activities he will be authorized to perform. Therefore credentialing is a process that benefits both the organization and the physicians as well as the public. Because of credentialing, physicians and organizations have aimed to improve the competence and quality of healthcare services they offer and provide. Credentialing raises the standards of healthcare organizations.
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