Credentialing

 Credentialing is the process to verify and assess your medical education, training and experience. Credentialing is one of the first steps young physicians will need to take when transitioning from training to practicing pediatrics.  Some organizations outsource credentialing. This can be very helpful to the organization and to you especially when you may be overwhelmed with other onboarding tasks. Employers help you in the credentialing process; however, those opening a new practice, either solo or with partners, will need to navigate this independently. However, there are companies you can hire to help. 

Typically you will need to be credentialed by:

• Hospitals where you intend to practice medicine, admit patients, consult on patients, have access to their EMR, order outpatient tests, or otherwise use hospital facilities. Hospitals have different levels of privileges depending on how much or how little you will be using these services. Check with the hospital’s Medical Staff Office as to what you will need.
• Insurance companies so that you can bill and be paid. 

You will need to go through the credentialing process with insurance companies whenever you change employers even though you already have been credentialed.  You will need to be re-credentialed at hospitals whenever you seek new privileges 

The Council for Affordable Quality Healthcare (CAQH) is a company the holds all of the information and documents you need for credentialing. It is used by almost all insurance companies to obtain up to date information for credentialing and needs to be updated every 90 days. It is funded by insurance companies, so it is free to you. You or your employer will need to set up an account with them. 

Note that each step of the credentialing process may take several months to complete. Start obtaining the necessary documents, licenses and identification numbers as soon as possible. Plan on a minimum time of at least 4 months from the time you first apply for your medical license. 

You will need several essential documents for credentialing:

• An active medical license: Without an active medical license (not a provisional license from residency), you cannot be credentialed by anyone. Apply for a medical license as soon as you know where you are going to practice, even though you may not yet have employment, as this process can take several months.
• A National Provider Identifier (NPI): This is a unique number used as a universal identification for all physicians and practices who bill insurance companies or order services for their patients though other agencies. Everyone should apply for an NPI.
• Tax Identification Number (TIN): Insurance companies will require you to have a TIN and a business bank account, as most insurance payments are direct deposits. Employed pediatricians will use their employer’s TIN. Those opening a new practice will need to obtain their own TIN.
• Proof of malpractice insurance: Malpractice insurance is typically provided by the practice or company you work for. If you are opening a new practice, you will need to obtain this on your own. Your new practice should be a corporation; and the corporation should be included on the malpractice policy.
• A Drug Enforcement Agency (DEA) license: If you plan to prescribe controlled substances such as medication for ADHD, you will need to apply for a DEA license.
• Contact information: Hospitals typically have a requirement that you be able to respond to emergencies within a certain time period. This will require you to provide them with both a home and office address so they can verify that you live/work within the appropriate response time. 

When in the job search process, keep this additional information handy for certification purposes:

• A government issued photo ID usually a driver’s license or passport.  
• Your education, training, and board eligibility or certification. If you’ve recently finished your residency training and are waiting to take the exam to complete your board certification, a letter from your residency program director indicating when you completed your training should be sufficient.  
• Your work, hospital medical staff, and hospital clinical privilege history.
• Names and contact information of colleagues, program directors or mentors who will provide timely references.
• If you have had any malpractice claims filed against you, be prepared to disclose them, with a brief history of the event and the outcome.  If you have had prior malpractice policies, information on them may also be required.  
• Records of the licenses for other states where you have practiced, even if they are inactive.  The Federation of State Medical Boards is a centralized resource for the contact information of each state board.
• Records of any prior disciplinary actions that may have occurred by hospitals, licensing boards or other medical professional agencies and their outcomes. 

Tips for Completing Applications

• Be scrupulously honest when filling out application forms. Giving false information can result in the loss of your medical license, loss of hospital privileges, or insurance credentials. Giving false information on a Medicaid or Medicare application can result in you being barred from participating in any medical programs that receive federal funding. In some cases, there can be legal repercussions.
• These applications will ask you about sensitive information such as criminal record, medical malpractice suits, disciplinary action, history of substance use, or medical condition that my interfere with your ability to practice medicine. Pay attention to the question and answer truthfully.