What is the difference between medical credentialing and privileging?

Medical credentialing and privileging are two significant things for a physician to practice at a medical facility or a hospital legally. Sometimes credentialing and privileging are confused with each other. For people who have entered the healthcare industry, it is important to know the difference between the two. 

What is Credentialing? 

Credentialing is the process that verifies and assesses the medical qualification and licenses of a medical practitioner to make sure that the individual is eligible and competitive enough to practice medicine in a healthcare facility. 

Credentialing involves the CVOs (Credentialing Verification Organizations) contacting various other organizations like medical schools, medical boards, and other associated entities. In this process, the CVOs make sure that the applicant has no previous record that shows they are not capable of practicing medicine. 

What is Privileging? 

Privileging is the process that authorizes a medical practitioner to provide certain patient care services. Privileging makes sure that the medical practitioner is qualified enough to provide their services to the patients and meet all the required needs of the hospital or medical facility. 

During the credentialing process, the CVO gathers information and based on this information, the credentialing committee determines privileging. Privileges can be divided into two categories. The primary privileges mean the routine privileges that healthcare providers learn during residency programs for their respective specialties. Specialty privileges, on the other hand, are non-routine privileges that require more training, and the CVO may ask for some additional documents for it. 

CMS requirements for privileging 

The Centers for Medicare and Medicaid Services laid the requirements for staff privileging mentioned in the CMS letter dated November 12, 2004. According to the letter, the governing bodies of hospitals require privileging authority before they start their services. 

• For Governing Body – The governing body must ensure that under no circumstances is the accordance of staff membership or professional privileges in the hospital dependent solely upon certification, fellowship, or membership in a specialty body or society. 
• For Medical Staff – The medical staff must follow the by-laws to carry out its responsibilities. 

Healthcare organizations to which privileging is applicable 

CMS quality standards apply to many health care organizations along with privileging. This includes mental or behavioral health centers, surgery centers, and federally qualified health centers (FQHCs).  

Credentialing and Privileging: Similarities 

Medical credentialing and privileging are required before practicing in any medical facility; otherwise, it can raise legal actions against the hospital. Hospitals and medical facilities, thus, follow thorough procedures for credentialing and privileging. 

In order to ensure quality patient care, and the best services, National Committee for Quality Assurance (NCQA), the Centers for Medicare and Medicaid Services (CMS), and Health and Human Services (HHS) require that medical practitioners and other health staff are properly privileged and credentialed. 

Medical credentialing and privileging are both a must for medical practitioners to provide their services at a medical facility. For hospitals and for practitioners, both processes are important to avoid any compliance issues and face any legal obligations.