Need to Know Facts About Credentialing, Privileging, and Enrollment for FQHC Executive Leadership

As the leader of a Federally Qualified Health Center (FQHC), you aren’t going to be hands on with credentialing and privileging, but it’s important to know the ins and out of the requirements so you can engage the right tools and resources to get the job done.

First and foremost, it’s important to understand the difference between credentialing and privileging.

What is the difference between credentialing and privileging?

Credentialing typically allows an organization to offer membership/appointment to a provider upon successful certification of the provider’s credentials such as education, training, certification, etc. The credentialing of a provider is a prerequisite to enrolling a provider with payers.

Privileging defines the services that a provider can provide to patients. Privileging requires a provider to “pass” credentialing plus achieve additional requirements related to specific privilege. For example, a provider may be required to be certified in advanced life support in order to provide moderate sedation.

If you are a federally qualified health center, you are required to privilege your providers under regulation from HRSA and others. FQHCs actually must privilege a wider scope of providers than most healthcare organizations are required to.

The type of providers FQHCs must credential and privilege include:

1. Licensed Independent Practitioners (LIPs)

This includes Physicians, Dentists, Physician Assistants and Nurse Practitioners



2. Other Licensed or Certified Practitioners (OCLPs)

This includes Registered Nurses, Licensed Practical Nurses, Registered Dieticians, and Certified Medical Assistants



3. Other Clinical Staff (OCS)

This includes Medical Assistants and Community Health Workers (in states or territories that do not require licensure or certification)

Why is it important to credential and privilege my providers?

There are many agencies that require and enforce credentialing and privileging requirements for FQHCs. These include:

• State licensing boards
• The Center for Medicare & Medicaid Services (CMS)
• The Department of Health & Human Services (HHS)
• And, other accreditation bodies such as The Joint Commission (TJC)

But complying with industry regulations is just one reason to credential and privilege your providers. According to Vicki Searcy, VP, Consulting, VerityStream, “The most important reason your FQHC should credential and privilege providers is to ensure that your providers are competent to provide services to your patients. Credentialing and privileging are not just exercises that you go through in order to check off a few boxes. They are important processes that safeguard patient safety.”

Fact is, according the NACHC, the number of patients being served by FQHCs continues to grow exponentially – making ensuring patient safety more critical than ever before. Their Community Health Center Chartbook highlights that nationally there are now 1375 FQHCs serving close to 30 million patients.

FQHCs that fail to effectively credential and privilege providers might also run into difficulty in meeting regulatory requirements, loss of community trust, lawsuits, and challenges achieving in enrollment with payers which will result in failure to get reimbursed for services rendered.

What does enrollment mean for my FQHC?

In order to receive payment for the services you offer to patients, you must enroll your providers for participation in insurance plans, networks, Medicare and Medicaid. Poor enrollment practices can cause significant delays or denials in payments. According to Searcy, “Most enrollment delays are due to insufficient or untrained staff and or a lack of automation.” If you’re currently experiencing an uptick in delays and denials, you’re not alone. In fact, a 2021 MGMA survey of medical practices revealed that 54% of respondents had experienced an increase of denials during 2021.

How do I set up successful credentialing and privileging processes?

Setting up successful credentialing and privileging processes doesn’t have to be difficult. The process can be summarized into the following seven steps:

#1 Establish policies and procedures that describe your credentialing and privileging processes.

#2 Create privilege delineations (or forms) that describe the clinical activities your FQHC will engage in.

#3 Develop an application and a list of required documents that must be submitted with the application. These documents might include proof of education and training, work history, etc. Much of this information will be required for enrollment, so gathering it at the time of application will speed up enrollment and create a better experience for your providers.

#4 Establish verification processes for both initial credentialing and recredentialing (which will be required every two to three years). Typical items that must be verified include:

• Licensure
• DEA and CDS
• Education/training
• Board certifications
• Work history
• History of malpractice settlements/judgements

#5 Define a decision-making process. This process will vary depending upon the size and/or complexity of your organization, but it will must certainly involve some physicians and representatives of your board or management team.

#6 Set up ongoing monitoring of expirables. Providers need to keep up licenses, certifications and more, and you need a way to ensure this is all done in the intervals between credentialing events.

#7 Implement all of the above. Automation delivered by credentialing and privileging software like CredentialStream can be extremely helpful with automation.

Once you have a credentialing and privileging process in place, you can establish an enrollment process. There are many variations of this process but most involve:

• Establishing policies and procedures that describe the enrollment process
• Submitting the documents required by each payer
• Preforming steps unique to each contract
• Monitoring the process closely

How do I ensure my credentialing, privileging and enrollment programs are working?

The volume of work (and associated costs) will help you determine whether you should manage credentialing and privileging in house or outsource to a Credentials Verification Organization or CVO. If you decide to manage the process in house, you will want to be sure you have the appropriate tools (like CredentialStream) and that your staff is trained. It’s a great idea to engage in trial runs of surveys to ensure that you are in compliance with requirements prior to actual surveys. You will want to pay attention to metrics – such as delays and denials of payments – to benchmark your performance and initiate continuous improvements.

It’s a lot to manage, but you don’t have to go at it alone. Encourage your team to check out our webinar: What FQHC Executive Leadership Should Know About Credentialing, Privileging, and Enrollment and to enroll in our Privileging 101 Series. In just 5 sessions, we cover all the fundamentals your team needs to know to become privileging pros!