Credentialing is the process by which a hospital or a health insurer checks that a doctor is properly licensed, trained and safe, before the doctor may treat patients there. Credentialing software collects the doctor's documents, checks each one with the body that issued it, and tracks when each one expires. Most of this software is sold in the United States, where every hospital and every health insurer must credential its doctors.
The checks are made at the source. This is called primary source verification. The software does not trust a photocopy of a licence sent by the doctor. Instead, it checks the licence directly with the state medical board, the government body that licenses doctors in that state. In the same way, it checks the medical school, the residency (the years of hospital training after medical school), the specialist board certificate, and a national database of past malpractice payments and disciplinary actions. Background verification adds a check for criminal records.
There are two kinds of buyer. A hospital credentials a surgeon and then grants privileges. Privileges are the specific procedures that the surgeon may perform in that hospital, such as hip replacements but not spine surgery. A health plan, which is what an American health insurer is called, credentials a doctor before adding the doctor to its network. A network is the list of doctors whose bills the plan will pay at agreed rates. The plan's health plan administration system then holds that doctor's contract and rates.
Take, for example, a hospital in Pennsylvania that hires an orthopaedic surgeon from another state. The surgeon fills in one online application and uploads her documents. The software checks her new Pennsylvania licence, her training and her board certificate, and finds no malpractice payments. A committee of senior doctors reviews the file and grants her privileges for hip and knee replacements. The whole process takes about 60 days. Until it ends, the surgeon cannot operate, and the hospital cannot bill for her work. So the speed of the software matters to the hospital.
Credentialing is not done once. Hospitals and plans must repeat it every two or three years, and the software warns before a licence expires. Some companies sell credentialing as an API: a digital-health company sends a doctor's details from its own software, and receives the verified result back automatically. The verified list of doctors then goes to provider data management. Insurance has the same idea for its sales agents, called producer licensing.
In India, hospitals that apply for NABH accreditation do the same checks. They confirm each doctor's registration with the National Medical Commission or a state medical council, and they grant privileges through a committee. Most Indian hospitals still do this with files and spreadsheets rather than specialised software.