Things to know about credentialing at Munroe

Why is Credentialing so important?

  • Munroe's bottom line is to provide quality patient care and the kind of healthcare we would want for ourselves and our families, in partnership with those we serve.
  • Munroe is liable for the practitioners it credentials.
  • We can never assume that someone else has done the work for us.
  • We must go through the proper process to protect our care providers from any unfair practices.

What if I have questions or concerns?

You may contact the Medical Staff Office:

Mary D. Dijkstra, Manager
Munroe Regional Medical Center
1500 S.W. 1st Avenue
Post Office Box 6000
Ocala, FL 34478
(352) 351-7392, #2
(352) 351-7246 fax
Email: MaryDijkstra@mrhs.org


The Board's Role

It is in Munroe's best interest for the Board to understand the credentialing process. The Board must be prepared to give a reason to regulatory agencies, customers, and the State why they have granted someone membership and/or privileges at this medical center. According to The Joint Commission standards, the Board is the ultimate authority in the credentialing and recredentialing process. The Board must depend on the clinical knowledge of the Medical Staff who have made the recommendations to the Board, the Senior Vice President of Medical Affairs who oversees the process, and the Medical Staff Office who does the background work that brings it all together.


Credentialing Definitions

Associate Provisional Status

  • A practitioner is initially granted Associate Provisional Status for a finite period of time (usually 1 year).
  • Associate Provisional practitioners have performance review by the Department Chair after the first six months on the Medical Staff.
  • At the end of the Associate Provisional period, performance reports and Department Chair recommendations are reviewed by the Credentials/Medical Executive Committee who forward recommendations to the Board.
  • Board reviews the information and takes action.

Ongoing Performance Monitoring

The Quality Management Department puts together a Physician Activity Profile that contains information relative to the past two years performance and practitioner's practice patterns including:
  • Number of admissions.
  • Number of consults.
  • Number of procedures.
  • Number of deliveries, etc.
  • Mortality rates.
  • Average length of stay.
  • Moderate Sedation documentation.
  • Delinquent medical records.
  • Complaints/Compliments.
  • Number of cases to peer review.
  • Results of surgical case review.
  • Medication errors.
  • All peer review.

Credentialing FAQs


What is credentialing?

The Joint Commission defines credentialing as the process of assessing and validating the qualifications of a licensed independent practitioner (LIP) to provide health services.

Credentialing is a two-phase process:
  • The first step is to consider and specify minimum requirements for entry into some status, such as medical staff membership.
  • The second step is the assessment and validation of clinician's qualifications against the established criteria.

What is Core Privileging?

Grouping procedures (that a fully trained physician is taught in his or her specific training program and should be qualified to perform) into a single privilege for a particular specialty.

Additional procedures that go beyond the core and require additional training and/or experience are listed separately.

Specific criteria are developed to perform procedures that fall outside of core privileges.


What is Privileging?

  • Determining the clinical procedures and treatments that should be offered to patients.
  • Determining the training and experience requirements necessary to authorize a practitioner to carry out each procedure or treatment.
  • Evaluating the qualifications of applicants using appropriate criteria and officially approving or denying requested privileges.

Why do hospitals credential physicians?

  • Ensure high quality patient care by protecting the public from incompetent practitioners.
  • Minimize the hospital's legal risk.
  • The Joint Commission or other regulatory requirement.

Why does Munroe Primary Source Verify?

Direct contact with the source(s) of credentials, such as medical schools, residency programs, licensing agencies, specialty boards and other healthcare entities, to guarantee that statements of education, training, experience and other qualifications are legitimate, unchallenged and appropriate.


Credentialing Process

What happens first?

  • An application is sent.
  • Upon review of the application if approved for processing, a confirmation letter is sent to the applicant.
  • The confirmation letter is sent when the determination has been made the applicant meets threshold criteria to become a member of the Medical Staff of Munroe Regional Medical Center.

The initial appointment packet includes:

  • Application forms.
  • Clinical Privilege delineation form(s) for selecting those procedures and services he or she would like to perform.
  • A copy of the Medical Staff Bylaws.
  • A cover letter requesting the following documents:
    • Current FL License
    • Current DEA Certificate
    • Copies of Diplomas (Medical School, Internship, Residency, Fellowship)
    • ECFMG (if applicable)
    • Evidence of Professional Liability Coverage
    • Procedure Log
    • Visa Status (if applicable)
    • Curriculum Vitae
    • Application fee
    • Current photograph

Upon Receiving the Completed Application Packet:

  • The application is carefully screened for completeness. Incomplete applications are returned to the physician for completion. Gaps in service must be explained.
  • Electronic Queries are made to:
    • The National Practitioner Data Bank
    • The Licensing Board(s)
    • Office of the Inspector General (OIG) for Medicare/Medicaid Sanctions
    • AMA or AOA for physician profile
    • Florida Department of Insurance
    • Certifacts for verification of Board Certification
    • HP Check Kroll Background America (Criminal Background Check)
    • Primary Source Verification of clinical competency from Internship, Residency, Fellowship training, etc.
    • Primary Source Verification of clinical competency from all Affiliations.
    • Primary Source Verification of clinical competency from three peer references.
    • Primary Source Verification of Malpractice History obtained from individual insurance carriers.
  • Primary Source Verification of clinical competency from all Affiliations.
  • Primary Source Verification of clinical competency from three peer references.

When Everything is Complete

  • The Medical Staff Office screens the application noting any gaps in service, liability cases, professional misconduct cases, loss of privileges and any other concerns for review by the credentialing bodies.
  • Verifications and peer references are reviewed for any negative or questionable content.
  • A packet with all the application's documentation is submitted to the appropriate Department Chair for review.
  • Application is taken to Credentials Committee for review.

Credentials Committee

  • The Credentials Committee consists of the five past presidents of the Medical Staff who serve a five-year term. The Credentials Committee may ask the practitioner for more information.
  • Credentials Committee carefully reviews all information in application folder.

Then What?

  • Credentials Committee/Medical Executive Committee review the application.
  • Either committee may request further information prior to making a recommendation.
  • Once satisfied, the committees make their recommendation to the Board to grant or deny membership and/or clinical privileges.

To the Board

  • The Board reviews the applicant's information. The Medical Staff President and/or Vice President of Medical Affairs are present to discuss and answer any questions. The Board grants final approval of the application for appointment or denies appointment.
  • If approved, the Medical Staff Office announces that the applicant has been granted Membership and/or Clinical Privileges.
  • The applicant receives a letter from the Vice President of Medical Affairs informing him or her of the Board's decision.
  • The Medical Staff Office arranges a formal orientation to Munroe for the physician if upon completion of the Department Chair interview if it has not already been done.

What if it's not approved

  • More documentation may be required of the applicant prior to final action by the Board.
  • If application is denied, physician may appeal via the Fair Hearing Process.

    All physicians on Munroe's Medical Staff must apply for reappointment every two years. The application process for reappointment is similar in many ways to the original appointment process.

    • The reapplication is sent to the physician.
    • Upon its return, the Medical Staff Office reviews it for completeness and primary source verification is obtained wherever necessary.
    • Reference forms are obtained from peers if the physician is a low volume practitioner.
    • Verification of competency in the requested privileges is obtained.
    • Verification of affiliations are obtained wherever appropriate.
    • When the reapplication is complete, the application and Physician Activity Profile are submitted to the Department Chair for review and his or her recommendation.
    • The Credentials/Medical Executive Committees review the reapplication, profile and Department Chair recommendation and make a recommendation to the Board.
    • The rest of the process is the same as initial appointments with the Board acting on the information received from the Department Chairs and Credentials and Medical Executive Committees.
    • Physicians denied reappointment may elect to undergo the Fair Hearing Process.