The NAMSS specifies 13 fundamental criteria for initial provider credentialing. Discover the steps healthcare organizations need to take to streamline credentialing procedures.

The credentialing process remains a cornerstone of ensuring high-quality patient care and operational integrity. With a recent survey by ProviderTrust and Healthcare Dive revealing that 95% of payer respondents are set to prioritize provider data within two years due to active fraud and regulatory shifts, the importance of credentialing cannot be overstated. Moreover, operational challenges loom large, with 64% of credentialing teams reporting an increased workload and 30% facing an unmanageable backlog, underscoring the need for streamlined and efficient credentialing practices.

In response, the National Association of Medical Staff Services (NAMSS) identifies 13 essential criteria for the initial credentialing of practitioner applicants. This framework aims to elevate the standards of provider verification, ensuring that healthcare organizations can trust the competence and integrity of their medical staff.

Moreover, with roughly 80% of providers expressing dissatisfaction with their organizations’ management of the credentialing process, citing issues such as excessive paperwork, complexity, and prolonged time to acceptance, the relevance of adopting NAMSS' streamlined approach becomes even more pronounced.

This article dives into these critical elements, offering insights into how healthcare organizations can refine their credentialing processes.

Optimizing Credentialing Standards for Initial Practitioner Applicants with NAMSS’ Best Practices

The National Association of Medical Staff Services (NAMSS) delineates an evidence-based framework for credentialing initial practitioner applicants, emphasizing the verification of 13 critical criteria from primary sources. This approach ensures a thorough and vetted assessment of an applicant's professional competence and conduct, which is crucial for identifying candidates requiring further investigation or deemed unsuitable for credentialing.

The Ideal Credentialing Standards for Initial Practitioner Applicants

1. Proof of Identity

The first step in the credentialing process involves confirming the applicant's identity through government-issued photo identification, such as a current driver’s license or passport. This verification process is foundational, ensuring that the practitioner’s identity matches the provided documents, thereby establishing the authenticity of the applicant at the outset.

2. Education and Training

Credentialing requires a complete verification of an applicant’s educational and training background, including medical school, internships, residencies, fellowships, or any clinical education/degrees, with a focus on completion dates and any gaps in education.

The process scrutinizes completion status, time gaps over 30 days, changes in programs, and, if applicable, Fifth Pathway certification and Educational Commission for Foreign Medical Graduates (ECFMG) certification. Contact information for the training program director is also sought for applicants who graduated within the past three years, ensuring a direct source of verification for recent education.

3. Time Gaps

This criterion mandates verification of all listed education and training, including start and end dates, as well as any gaps exceeding 30 days. Applicants must provide written explanations for these gaps, offering insight into their training and any potential concerns regarding their educational journey. This helps in identifying any undisclosed issues that may affect their suitability for credentialing.

Primary sources may include state regulation, applicable professional and training schools or residency training programs, NSC, AMA, AOA, ECFMG, FSMB, state medical boards, and applicant explanations.

4. Professional Licensure Verification

This involves verifying the completeness of an applicant’s licensure information, including:

  • Issuing state,
  • License type,
  • Number, status,
  • Validity dates.

Verification from state licensing boards, the Federation of State Medical Boards (FSMB), the American Medical Association (AMA) Masterfile, and the American Osteopathic Association (AOA) Profile ensures the accuracy and current standing of each license. Along with investigating any undisclosed licenses, sanctions, or disciplinary actions.

Red Flag Examples include undisclosed licenses, pending investigations, and disciplinary actions.

5. DEA and Controlled Substances Certifications

Verification of Drug Enforcement Administration (DEA) registration’s and state Department of Public Safety (DPS) and Controlled Dangerous Substances (CDS) certifications’ accuracy and current status, including appropriate DEA/State Bureau schedules for the practitioner’s field, is crucial for prescribing medication. Primary verification from the DEA, state DPS, and state CDS authorities.

Red Flag Examples include any revocation, investigation, or undisclosed certifications.

6. Board Certification Verification

Verification encompasses the review of all board certifications held by the applicant, including original and recertification dates, and participation in maintenance of certification programs. Validation from direct sources like the American Board of Medical Specialties (ABMS), AMA, AOA, American Nurses Credentialing Center, and others ensures that the certifications are current and relevant.

Red Flag Examples include lapsed certifications or multiple failed attempts at certification.

7. Practice History Timeline Verification

A detailed review of a practitioner’s practice history timeline covers affiliations, employment/work history, and military service through gathering a comprehensive, chronological list of all facilities where clinical privileges were held since the completion of training.

For locum tenens or telemedicine practitioners, the ten most recent/active affiliations are specifically reviewed.

8. Criminal Background Disclosure

Criminal background checks are conducted using federal, state, and county databases to assess any criminal activity within the last seven years. This encompasses a County Criminal Search and a National Criminal Search, delving into areas such as sex-offender registries and terrorist activity records.

9. Sanctions Disclosure/Government Database Checks

Sanctions or licensure restrictions disclosed through queries of federal and state databases can have significant implications for a practitioner's eligibility. The National Practitioner Data Bank (NPDB) Continuous Query, the Office of Inspector General’s (OIG) List of Excluded Individuals/Entities, and the System for Award Management (SAM) are primary sources for such verifications.

These checks help in identifying any sanctions, exclusions, or disciplinary actions that might affect a practitioner’s ability to participate in healthcare programs or perform clinical duties.

10. Health Status Inquiry

Adhering to the guidelines of the Dr. Lorna Breen Health Care Provider Protection Act of 2021, inquiries about a practitioner’s health status focus on conditions that could impair their ability to practice medicine competently, ethically, and professionally.

This approach prioritizes the mental and physical well-being of practitioners, ensuring they are in a position to provide safe and effective care.

11. National Practitioner Data Bank (NPDB) Queries

The NPDB is an essential tool for verifying healthcare-specific information such as state and federal criminal convictions, civil judgments, malpractice history, and hospital sanctions. Medical Services Professionals (MSPs) are required to query the NPDB during the initial credentialing process and on a continuous basis thereafter, ensuring ongoing compliance with the Health Care Quality Improvement Act of 1986.

Discrepancies between the information provided by the applicant and the NPDB reports, or a pattern of reports, are significant red flags that necessitate further investigation.

12. Malpractice Verification

The applicant must have current professional liability coverage consistent with the clinical privileges requested and without exclusions.

A comprehensive list of all current and past malpractice insurance carriers for at least the past five years, including coverage dates, types, and policy numbers, must be obtained. Unverified coverage, a pattern of claims, or discrepancies in insurance dates are red flags that warrant a detailed review.

13. Professional and Peer References

Professional and peer references, ideally from individuals who have worked closely with the applicant in the past two years, provide authoritative perspectives on the applicant's experience and suitability for the requested clinical privileges. References are also asked to comment on any health issues that might impair the applicant's ability to practice medicine competently.

Missing data, low competency ratings, or a lack of response from past affiliations are considered red flags, highlighting potential concerns about the applicant’s fitness for practice.

Additional Suggestions for Initial Credentialing

The 2024 NAMSS recommendations for initial credentialing extend beyond the core 13 standards, incorporating additional practices for a more comprehensive evaluation of applicants for privileges. These suggestions, though not mandatory, provide valuable insights and are adaptable according to each organization's specific needs and policies.

  • Internet Background Checks: Recognizing the vast repository of information available online, NAMSS suggests conducting internet background checks on applicants. This process can uncover a plethora of potentially relevant information that might not be captured through traditional credentialing methods.

  • Social Media Reviews: In an era where digital footprints are as telling as real-world interactions, reviewing an applicant's public social media profiles can offer additional insights into their professionalism and conduct. NAMSS advises approaching this practice with caution, responsibly integrating social media findings into the overall evaluation.

These additional practices underscore that credentialing remains a dynamic and comprehensive approach to upholding the highest standards of healthcare professionalism and patient safety.

Streamline Your Credentialing Process

To address the complexities and challenges highlighted throughout the credentialing process, healthcare organizations are increasingly turning towards innovative solutions that offer efficiency, accuracy, and provider-centric strategies. These software systems boast user-friendly interfaces and are equipped with robust automation features, such as automatic reminders for document expiration dates and seamless integration with CAQH, ensuring that the credentialing process is not only streamlined but also compliant with current standards and regulations. Credsy helps manage licensing, monitoring, and credentialing across states. Its user-friendly analytics, easy navigation, and straightforward setup of role-based permissions make it an ideal choice for environments keen on continuous operational improvement. Reach out to us and make managing your provider network easy in any state. At scale.

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