As a new resident at St. Luke’s Hospital in St. Louis, internal medicine physician Sara Hawatmeh, M.D., had already secured her state medical license before starting residency, thanks to the help of her residency coordinator. After finishing postgraduate training, she had to become licensed as an independent physician. That process was also an easy one, since the state allows physicians to apply for future issuance. As a result, she had her new license within a day of her residency license expiration. However, the insurance credentialing process was a different story. "It was a nightmare," Hawatmeh says.
Physicians across the country know that getting your state license, insurance license and hospital privileges is often a matter of "hurry up and wait." The hurry up part is usually doable, but the waiting is agony. According to the American Medical Association, physicians should plan for at least a 60-day window between submitting a completed licensing application and the actual licensure granting date. Those who, like Hawatmeh, graduated from medical school outside the U.S. should expect it to take slightly longer. State medical licensing boards need time to evaluate each application fairly. But that’s not where Hawatmeh, who is now in private practice with her father, ran into the majority of her delays.
Hawatmeh hired a third-party company to help with credentialing. She was told the process would take about 90 days. It took much longer. "I think it was about nine months before I was officially credentialed," she recalls. If just one document is kicked back for missing, outdated or inaccurate information, the process will slow down or even grind to a halt. "The whole process was delayed by maybe a month due to a misplaced signature," Hawatmeh says. She resubmitted documents, only to find out they still weren’t correct, without any explanation why. Later, she was told the documents had not been received, although she had proof that they had.
The process may not be as difficult for employees of hospitals or group practices. Hawatmeh says larger organizations have experienced staffers trained to navigate the process. "No one teaches you these things in residency," she explains. "They send you out into the world, and you are expected to figure out."
Although California- and Florida-based facial plastic surgeon Demetri Arnaoutakis, M.D., never dealt with the same delayed timeframes as Hawatmeh, he shares her frustrations about the mass of paperwork. "When you’re a physician and busy seeing patients all day or even a surgeon in the operating room, you can’t multitask when it comes to that stuff. You are expected to do the paperwork yourself without delegating it, so it takes time to gather all the documents and type out all the information needed. It’s a laborious process," he says.
Arnaoutakis earned his medical degree at the University of Florida College of Medicine, then spent a year at Johns Hopkins hospital doing head and neck cancer reconstruction research. He then trained in head and neck surgery at UT Southwestern Medical Center in Dallas before doing a facial plastic surgery cosmetic fellowship in Beverly Hills. Each time he moved, he had to go through new state licensing.
"For example, when in California and trying to open an office in Florida, I had to get a Florida medical license, even though I already had a medical license in both Texas and California," explains Arnaoutakis. He says getting his license in Texas took the most time. "Compared to Texas, where it took at least four to five months to process, I was surprised at how quick licensing happened in both California and Florida," he says.
Family medicine specialist Ashley Hartt Anderson, D.O., holds medical licensure in both Texas and California. Unlike many other states, Texas requires physicians to pass a jurisprudence exam, so most people advise keeping the Texas medical license current once you have it.
However, Anderson says getting a California medical license wasn’t exactly quick or easy either. "It took months to get my license despite me being a military spouse and supposedly granted an expedited process." She says the biggest difference between California and Texas is that California has two medical boards: one for M.D.s and the other for D.O.s. "I had no clue this was even a thing, since we have only one [governing body] in Texas," she explains. Although Anderson went to a D.O. school, she trained at an allopathic residency program and didn’t take D.O. board exams past the ones required for medical school.
She also encountered snags with fingerprinting. "Since I wasn’t living in California, there was a special process to have it done," she says. "The first set of fingerprints were invalid for some reason, which further delayed the process." As a military physician, her husband had a totally different experience. "Military physicians can be licensed in any state, and he holds his from the state of Virginia," she explains. "There, it is a very simple and relatively cheap process, and as a result, most military doctors get licensed in Virginia."
Physicians have to wait on medical boards before they can practice, but that’s not the only hurdle to clear. The employer credentialing process can also involve delays and more paperwork. Senior director of site operations for US Acute Care Solutions Melissa Reese - who identifies as a credentialing geek - says, "We often expect that since doctors have gone through so much training that the credentialing process would be simple for them, but it’s just not something they are experts in."
That’s why Reese and her team of 20 credentialing professionals work closely with their clinicians and hospital partners to ensure a smooth onboarding process. Reese says, "We coach our physicians through the process. It’s something they appreciate. We’ve had doctors leave and then return to the practice who later share their gratefulness for our process because not all organizations offer such credentialing help."
Before beginning employment, a physician has to produce documents and fill out forms that rival daily EMR documentation. Reese says the vital elements for employment credentials and hospital privileges fall into five common areas:
Basic demographic information. For starters, you’ll need to fill out your full name, address, birthdate, contact details, social security, DEA, NPI numbers, etc.
Work, education and training details. You’ll also have to provide copies of your medical school diploma, internship/residency completion documentation, and information about former employers and hospitals where you’ve held staff privileges.
Legal information. This information may have implications for malpractice or licensing issues. If you answer "yes" to any questions about board sanctions, a host of other documents will be required.
Peer references. Another important element is contact information for your peer references. Be sure to remind them to keep an eye out. If your references don’t respond to an email, it can delay the credentialing process - even if the initial request went into the spam folder or arrived while they were on vacation.
Competency documentation. Reese says more hospitals than not are now looking for proof of competency. They want to see a certain number of procedures in the last few years, ensuring that you have been actively working in your field.
Although there’s a strong call for uniform requirements among licensing boards, the idea of automatic reciprocity between state medical boards has mostly been tabled. Licensing and credentialing requirements vary for each state, facility and type of work. Reese says the biggest variations come from hospital systems with different processes, different bylaws and even different meeting cycles. "Most of our hospital partners will quote 60-90 days or 90-120 days," she explains. She adds that the group functions as an emergency department, so most hospital partners help prioritize their physicians.
Counterintuitively, new physicians have an advantage over experienced ones when it comes to credentialing. A doctor who has been in business for 20 years, worked at 30 different hospitals and held multiple state licenses will have more paperwork to deal with than one who is fresh out of residency. For a new medical graduate, Reese says the verification goes much faster, explaining, "The bigger their history, the longer it takes to complete the process."
Delays can happen at any point along the way. Since Arnaoutakis’s two older brothers are both physicians and had warned him about these delays, he was better prepared than most to face credentialing. But even he experienced long waits and overwhelming amounts of paperwork. Along with Hawatmeh and Anderson, he has some tips for new physicians about to face their first credentialing rodeo:
The arcane process of gathering documents, then submitting and resubmitting those documents for recertification, hospital privileges, a new employment contract or insurer certification is ripe for innovation. Hawatmeh, Anderson and Arnaoutakis all say a centralized, secure database could make the process much easier for clinicians.
Streamlining the process would help physicians who want to move states, add new insurers to their practices or offer Medicare and Medicaid. It would also enable groups and hospitals to onboard physicians faster. "So, if you are trying to get a license in Florida, California, Texas or New York, then perhaps they could just pull your information forms from a prior state in which you were practicing," says Arnaoutakis. "That would help facilitate things."
Some physicians pride themselves on being highly organized. They stay on top of the paperwork and record due dates for license renewal and hospital privileging information. Others rely on services like the Federation Credentials Verification Service (FCVS), which allows clinicians to establish a confidential, lifetime professional portfolio that can be forwarded upon request.
The money adds up. Spend hundreds of dollars for this license and hundreds for that certification, and before long, thousands of dollars have slipped through your fingers. Fortunately, a few companies, such as Austin-based Intiva Health, have started to address credentialing inefficiencies. Intiva Health was founded in 2006 as a staffing agency but has since created Ready Doc, a credential management platform that uses distributed ledger technology (DLT) to authenticate a document’s veracity over time.
The company’s roots are in practice management, placing anesthesiologists at hospital facilities. The CEO was looking for ways to automate the process, and over time, new technologies made it possible to create secure audit trails for documents. Intiva Health realized that adapting these technologies to health care could make the entire industry more efficient and prevent things from falling through the cracks.
Until that longed-for future when uniform medical board requirements exist and a central document repository is accessible, Hawatmeh and the other doctors have one message to impart: Don’t underestimate the time it takes for the credentialing process or the frustrations that may come with it.
Marcia Horn Noyes is a frequent contributor to PracticeLink Magazine.