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Using electronic provider credentialing to address the quality revolution.

S Shroyer1

  • 1Sweetwater Health Enterprises, Inc., Dallas, TX, USA.

Infocare : Information Strategies for Healthcare Networks
|December 9, 1995
PubMed
Summary

Provider credentialing is a key quality initiative for managed care organizations (MCOs). It offers significant advantages beyond basic background checks when integrated into a quality management system.

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Area of Science:

  • Healthcare Management
  • Quality Improvement

Background:

  • Provider credentialing is increasingly important for managed care organizations (MCOs).
  • Industry accreditation, driven by quality concerns from insurers, purchasers, and patients, necessitates credentialing.
  • Credentialing is often underutilized and misunderstood as a quality tool.

Purpose of the Study:

  • To highlight the strategic value of provider credentialing.
  • To emphasize that credentialing is foundational to a comprehensive quality management system.
  • To demonstrate benefits extending beyond routine background checks.

Main Methods:

  • Analysis of current practices in provider credentialing within MCOs.
  • Review of the role of credentialing in achieving industry accreditation.
  • Conceptual framework illustrating credentialing as a first step in quality management.

Main Results:

  • Credentialing is frequently performed but its potential is not fully realized.
  • Effective credentialing provides advantages significantly greater than basic verification.
  • Integration into a quality management system maximizes credentialing benefits.

Conclusions:

  • Provider credentialing is a critical component of quality initiatives in managed care.
  • Viewing credentialing as the initial phase of a quality management system unlocks its full potential.
  • Strategic implementation of credentialing yields substantial quality improvements.

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