To borrow from the driving drill, practicing “defensive verification” means verifying to save lives, time, and money, in spite of the conditions around you and the actions of others.

Done well, it may take more time upfront but it saves lives and money in the long run. It also takes fortitude, when enrollment specialist are faced with pressure to credential quickly and get providers par, and MSPs are under pressure to fast-track privilege delineation and/or staff membership. Consider how today’s technology easily enables healthcare providers or impostors to exaggerate or outright fabricate professional qualifications to gain exposure to patients. Verification truly is the best and first defense of safe, quality care delivery.

Whether your organization follows the regulations and standards of CMS, Joint Commission, DNV-GL, NCQA, or other body, here are some basics of practicing defensive verification.

What’s considered a primary source?

A great deal of credentialing’s effectiveness comes from the act of going directly to the source of the credential or the institution that issued the document—the action you know as primary source verification (PSV). You can also verify through a designated equivalent source, which is an accrediting agency’s approved agent of the source that has been determined to maintain specific credentialing items that are identical to the information at the primary source.

Note that obtaining original documents doesn’t necessarily constitute primary source verification, especially when the communication comes from the applicant themselves or through their agent. Resort to secondary sources (e.g., another healthcare facility, photos or photocopies of a credential verification, confirmation from a source who PSV’d the credential) only in cases where the true primary source is unavailable.

What methods are acceptable?

Information received directly from the issuing source can be received as:

  • Written communication (email, letter, or fax)
  • Phone (Document: name of organization, date, person contacted, questions asked, response, the name of the person receiving the response)
  • Approved web site

Extra mile: In addition to using primary sources, consider conducting backup research such as an online search including social media. Often, any negative articles or posts about the provider’s background or behavior can be unearthed this way.

Typical elements verified

Depending on your accreditor, state, and organization’s bylaws/regulations and policies, the range of elements that might be included in the verification of any provider include the following:

  • Personal identity (military ID, state ID, customs passport, state driver’s license)
  • Health status/ability to perform procedures (attestation, physician exam)
  • Professional licensure:
    • Some states also issue a controlled substance license in addition to the license to practice medicine
    • Some professions are regulated through registration or certification and not licensure
  • Education and training:
    • The school
    • American Medical Association (AMA) Physician Masterfile
    • A credentials verification organization
    • The Educational Commission for Foreign Medical Graduates (ECFMG)
    • The American Osteopathic Association (AOA) Physician Database
  • Experience/work history (*See sample letter link below)
  • Liability insurance coverage/Malpractice history (insurance company—past and current professional liability insurance carriers, including policy numbers, amounts, and dates of coverage)
  • Peer references (not partners, not related to applicant—who have personal knowledge of the quality of medicine practiced by the applicant)
  • Board certification (American Board of Medical Specialties, AOA, American Board of Physician Specialties)
  • Sanctions or disciplinary actions (DEA, CMS, NPDB, OIG/SAM)
Resource for work history/hospital affiliation

Click here to access a sample hospital affiliation letter you can customize.