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Why Provider Credentialing Is Important for Patients?

When it comes to healthcare, patients always trust that their providers have the necessary qualifications and expertise to provide safe and effective care. However, with many unlicensed physicians roaming the streets, how can patients be sure that their healthcare provider is qualified and competent? 

That’s where provider credentialing comes in. It plays a crucial role in ensuring patient safety, quality care, regulatory compliance, and insurance coverage. Here, we’ll discuss the importance of provider credentialing for patients and how it can help them make informed decisions about their healthcare. 

Ensures Quality Care

Physician credentialing is necessary to ensure patients get quality care from competent and qualified healthcare professionals. It also verifies a healthcare provider’s education, training, licensure, and other qualifications, giving patients enough confidence in their provider’s skills and expertise. 

For instance, imagine you’re searching for a new primary care physician and finding one who is licensed and credentialed by your insurance company. This means they underwent a rigorous review process and met specific requirements to be credentialed. Therefore, you’ll have the peace of mind that you’re getting quality care. 

Furthermore, if you need a specialist, your insurance company might only cover the cost of care by an accredited physician, ensuring your issues are addressed by a qualified professional. 

Ensures Patient Safety

Provider credentialing helps identify healthcare providers with a history of malpractice, misconduct, or disciplinary action, preventing them from continuing to offer substandard care that could harm patients. 

Suppose a patient seeking care from a new dentist finds out that the physician has been subject to disciplinary action due to a history of malpractice. However, the patient decides to ignore this information and proceeds with the treatment. Their decision can lead to a poor outcome or cause them harm. On the other hand, if the patient had checked the dentist’s credentials, they could've avoided the risk of harm or poor results associated with such a provider. 

Provides Insurance Coverage

Many insurance plans require healthcare providers to be credentialed to qualify for coverage. This requirement protects patients from having to bear the full cost of healthcare services. 

For example, a patient may have a health insurance plan that only covers services provided by credentialed providers. If they were to receive care from a non-credentialed doctor, they may be responsible for paying the entire cost of the service. This can be financially burdensome, preventing many patients from seeking necessary medical care in the future. 

Insurance companies use free credentialing software, such as CAQH re-attestation, to access provider information and qualifications. Once a quarter (every 120 days) providers are required to update their credentials, attesting that their information is current and correct. 

Ensures Regulatory Compliance

Regulatory bodies, such as state medical boards, often require healthcare providers to be credentialed before practicing medicine. 

For instance, imagine a patient seeking medical care from an unlicensed and non-credentialed dentist, The physician may be unauthorized to practice dentistry in that state, and may lack the required qualifications, skills, and knowledge to provide quality dental care. This can result in serious dental health complications in the long run. 

Protecting Patients from Substandard Care

By checking a healthcare provider’s credentials, patients can ensure their physicians have the necessary qualifications, skills, and knowledge to provide safe and effective care. This not only protects the patient’s health but also gives them peace of mind. 

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