The Process of Credentialing & Privileges

What is the process to get Credentialed and Privileges inside a hospital?

This credentialing and privileging process applies to all institutions that are required to have a medical executive committee (MEC) for purposes of granting hospital staff privileges. 

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What types of Employers Require Credentialing through a MEC?

If you are considering applying for hospital staff privileges, keep in mind that there are many other types of institutions that are required to do the same such as ambulatory surgery. physician provider organizations, preferred physician groups, managed care companies (MCOs), etc. When it comes to applying for privileges, it all starts with an inquiry letter, and then progresses through the application process. 

The Process to Apply for Privileges in a Hospital is as follows:

Request - Send the medical staff office (MSO) for the facility a letter, a long with a CV, and requesting an application packet for your specialty. 

  1. Application - The Medical staff office will then send you an application packet with instructions and forms, including an application, a conflict of interest form,  a release of information form, a form where you agree to abide by the hospitals rules and regulations, maybe even a confidentiality agreement, and there will be questions about your license(s) such as: the specialty certification, DEA #, Tax ID, Board Certifications, professional liability insurance. 
  2. Full and Complete Information is Required - Next you will complete the requested information.  Important: if you have issues in your history, such as a: prior law suit, licensing complaints, a potential conflict of interest, a pending law suit or a pending complaint, or any other certification or licensing issue like something that shows up on the National Provider Data Bank (NPDB), or issues where your privileges we reduced or revoked due to behavior or competency issues; you should probably consult an attorney to help you frame the application truthfully and accurately, and to help you maximize your chances of getting approved. Remember, if this information is not accurate, it means that the institution can terminate your privileges at any time. You will likely have to attach a copy of your graduation certificates and licenses with the application.  
  3. Application Verification - Your application will then be verified by the medical staff office, all licenses, certifications, and prior work history will be checked.  The MSO will inquire into your state license, National Practitioners' Data Bank, Medicare/Medicaid Fraud and Abuse Lists, and all sources of where a physicians disciplinary actions and claims are reported. 
  4. Department Chair Review - Next your application will go to the Department Chair for review of the file to see if it meets the qualification standards.  Important: The approval or disapproval at this step is key.  Most applications that are denied are denied at this stage, and the reason stated is "incomplete record or file"; however if the application proceeds to the next level and is then denied it is a reportable event that you were "denied privileges". So be very deliberate and careful in the application process, if the application goes bad, it will likely have other professional ramifications.
  5. Medical Staff Committee or Credentialing Committee or the Medical Executive Committee will then review your application for its approval.
  6. Board of Governors or Board of Trustees or the presiding governing body of the hospital system will then have the last opportunity to review the file and decide whether to grant the appointment and privileges 
  7. If and once you are approved, you will receive a written confirmation letter, and you may be placed on the "Call" schedule; you may also me asked to serve on on a medical staff committee. Roughly every 2 years after this appointment, you will likely have to go through the a similar disclosure and verification process.   

If you would like to find out more about what the power, role, and obligations of a Medical Executive Committee are, or if you would like to find out more how the peer review process works click on the links provided. 

If you have questions or issues you need to run by an attorney, please reach out to your select healthcare hospital attorney who has experience in handling this sort of stuff; if you don't then feel free to call us for we have the experience on how to guide you through this process.   

Below is a schematic of how the credentialing and privileging process works. 

Here is an informative webinar on how to protect yourself in Peer Review Hearing: How to Navigate - Hospital Medical Executive Committees, Peer Reviews, Investigations, and Bylaws.

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